Balance+Plus VNG Demo Doctor Questionnaire

[Please answer the following questions accurately and print clearly.]

1. If you could earn up to $2,500 for each demo performed, would you or a staff member
we train have a few hours a week to demonstrate our equipment? Yes ____ No ____

1a. How many hours a week would you or your staff member have available to this? ________

2. If you could earn $500 for just 30+ minutes answering questions about our equipment
from other physicians who are considering purchasing it, would you have the time? Yes ____ No ____

2a. How many hours a week would you have available for these consults? ________

3. Approximately how many patients do YOU see PER WEEK over the age of 60? ________

4. Including you, how many physicians work in the practice? ________

5. Approximately how many TOTAL patients over the age of 60 does THE PRACTICE see
PER WEEK (you and the other physicians in the office combined)? ________

6. On average, how many times PER YEAR would a patient over 60 come in to see you?

_____ 1 x PER YEAR   _____ 3 x PER YEAR   _____ 6 x PER YEAR   _____12 x PER YEAR

7. What percentage of your older patients are covered on a “fee for service” basis? _______%
[i.e., not an HMO, but pay using Medicare, commercial insurance, cash, etc.]

8. Do you currently test or treat patients for dizziness and balance problems? Yes ____ No ____

9. Do you currently own an ENG (Electronystagmography) System for testing? Yes ____ No ____

10. Do you currently own a VNG (Videonystagmography) System for testing? Yes ____ No ____

11. Do you currently use a “service” for testing patients with balance problems? Yes ____ No ____

12. Do you currently have an audiologist on staff, or do you use the services of one? Yes ____ No ____

13. What type of a physician are you?  M.D. __________  D.O. __________ Other _________________________________

14. What is your specialty? ______________________________________________________________________________

When would be the best day and time to call you:  Date _________________________  Time: ___________________

Name of Personal Scheduler: __________________________________  Backline Phone#: __________________________

Please fax this questionnaire to 561-793-5311. Once we receive it, we will create an income
projection detailing the benefits of offering this program and send it prior to our appointment.

Name: ____________________________________  Phone: ______________________  Fax: ______________________

E-mail: _________________________________________________________________ Cell: _______________________

[Balance-Plus Website]