Practice Profile

We enjoyed connecting with you and are excited about your continued interest in pursuing a partnership with Spine & Rehab Partners. Please take some time to fill out the questions below, as this will help us in evaluating your practice and determining the next steps.

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General Info

Name*
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Office Address*

Practice Details

Are x-ray taken in the practice?*

Financial Info

Check all payor types that you currently accept.*

Office Space

Location Type*
Do you lease or own the space?*
Current lease termination date (if renting)
Patient Records*

Staff Expenses

Please list all employee positions (specific names not needed) and their approximate compensation either by salary or hourly depending on how they are paid.
Include all W2 income and owner profit distributions.

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You’re Almost Done!

Thank you for taking the time to complete the practice profile.

After you’ve submitted the form above, please upload & submit the following documents. Alternatively, you can email them to: Align@SpineRehabPartners.com

  • P&L Financial Statements

    • P & L for 2024 Year to Date

    • P & L for 2023

    • P & L for 2022

    • P & L for the last 12 months combined

  • Current Balance Sheet

 

  • Practice Management Reports (if possible)
    • CPT Codes for 2023 and 2024 by # of units

    • Revenue by CPT code for 2023 and 2024

    • Revenue by Payor for 2023 and 2024

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