Prequalification & Operational Assessment Questionnaire

A tailored operational model for healthcare professionals in Texas.

This questionnaire helps us evaluate your eligibility, readiness, and operational needs so we can determine whether our turnkey healthcare operations model is a good fit and, if so, design a customized proposal aligned with your specialty, goals, and growth plans.

Completion of this questionnaire does not constitute an agreement or commitment by either party.

Are you applying as?
Have you previously owned or operated a business?
Professional Role
Are you currently licensed in the U.S.?
Are you currently located in this market?
Do you already have a location?
Do you require a private provider office?
Do you intend this to be:
Do you anticipate expanding clinical staff within the first 12 months?
Do you have experience using clinical or administrative software?
Are you open to adopting standardized software platforms?
Consultation Room – Furniture
• Physician chair
• Patient and companion seating
• Examination stool
• Height-adjustable step stool
• Scale with stadiometer
• Waste containers (municipal, biohazard, sharps)
• Storage cabinets for medications and supplies
• Examination table with stirrups
• Mayo / Pasteur adjustable table
• Desk with PC
• Clinical records storage

Medical Equipment
• Sphygmomanometer (manual or electronic)
• Binaural stethoscope
• Pinard stethoscope
• Diagnostic kit (ophthalmoscope optional)
• Adjustable examination lamp
• Ultrasound (optional)
• Vital signs monitor (optional)
• Emergency medical kit

Medical Instruments
• Covered container for disinfectant solutions
• Vaginal specula (optional)
• Scalpel handle
• Reflex hammer
• Ring forceps
• Tissue forceps (with and without teeth)
• Mosquito forceps
• Curved forceps
• Needle holder
• Kidney dish (250 ml or larger)
• Straight scissors
• Cotton applicator container
• Measuring tape
• Clinical thermometer
Reception Area
• Functional reception desk
• Ergonomic chair
• Computer with scheduling and records software
• Phone and internet
• Filing system or document scanner
• Office equipment (printer, stationery, prescription pads)
• Intercom or internal communication system

Waiting Area
• Comfortable seating (easy-to-clean materials)
• Adequate lighting and ventilation
• Side tables or magazine racks
• Water / coffee dispenser
• Signage (privacy notices, hours, staff information)
Select the hygiene and safety elements that will be implemented in your clinic
Do you understand that our company provides non-clinical operational and management services only, and that all medical decisions and patient care remain under the exclusive control of licensed healthcare professionals?
Have you ever been involved in:
Select if applicable:
Brief explanation
Please explain briefly
Please describe your preference
Additional comments (optional)
Agreement