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How can we help your facility?
Facility Name
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Facility Address
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Contact Name
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Phone number
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Email address
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What type of healthcare facility are you representing?
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Hospital
Ambulatory Surgery Center
Government Medical Facility
Private Practice
What services are you interested in? (Select all that apply)
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General Information
Perioperative Staffing
Allied Health / Diagnostic
Home Health
Contract Placement
Per-Diem Placement
What is the preferred method of communication?
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Email
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What is the urgency of your staffing needs?
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Immediate
Within 1 Month
Within 3 Months
Flexible
Which service or services are you in need? (Select all that apply)
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Perioperative Services
Diagnostic Services
Home Health Nursing
Per-Diem Staffing
Contract Staffing
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