Request For Proposal | Concierge Anesthesia

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REQUEST FOR PROPOSAL

CONTACT INFORMATION

First Name

Practice / Organization

Last Name

Specialty

Email Address

Phone Number

Address

GENERAL INFORMATION

What is your facility accreditation

Is your facility in-network?

If yes, Please list or upload documentation

Upload File

Upload supported file (Max 15MB)

How many ORs?

How many cases done per day?

Surgical Specialties

Plastics & Cosmetic Surgery

Gastroenterology

Pain Management

Vascular

Orthopedics & Spine Surgery

General Surgery

Oral & Dental Surgery

ENT

Uralogy

Gynecology

How many treatment/procedure rooms?

How many ORs and/or treatment rooms are ran daily?

What days will anesthesia services be needed?

Mon

Tue

Wed

Thu

Fri

Sat

Service Interest

Anesthesia Staffing

Anesthesia Billing & Consulting

ASC Anesthesia

Surgical Hospital Anesthesia

Office-based Anesthesia

When would you like services initiated?

In next 30 days

In next 2-3 months

In next 3-6 months

In next 6-9 months

In next 9-12 months

How did you hear about us?

COMMENTS & QUESTIONS

Thanks for submitting!

Concierge Anesthesia Consultants

info@conciergeac.com Ph: 281-901-5684 Fax: 281-819-3305

12335 Kingsride Lane #236 Houston, TX 77024

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