Clients Application
Please take a moment to fill out this information form. Ultrasound Temps, Inc. will use this information to ensure that we have a properly suited sonographer for your location.
Name of Facility:
Address1: Address2:
City:
State: Please Select ---------------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:
Contact Name:
Email Address:
Main Phone Number: Lab Phone Number:
How did you find out about us?
Please check all that apply.
1. What is important to your practice? Ability to call up last minute to get a Temp for an assignment. Ability to call up in advance and schedule a Temp for a scheduled assignment.
2. What are your facilities hours of operation?
3. What qualifications do you require of a temporary sonographer? Registered Diagnostic Medical Sonographer (RDMS, RVT, RDCS) Pending Certification Either is acceptable, providing they are experienced.
4. What is an acceptable dress code for a temp sonographer at your facility? Professional clothes under a lab coat. White uniform & lab coat Colored/floral scrubs Other:
5. How often are patients scheduled for ultrasound examinations? Every 30 minutes Every 45 minutes Every hour
6. What is the average ultrasound patient load, per sonographer, on a typical day at your facility? 3-4 patients 5-10 patients 10-15 patients 15-20 patients Greater than 20 patients
7. When Ultrasound Temps Inc. provides coverage to your facility, would the temporary sonographer be working alone or with other sonographer’s in the department? Alone in the department With other sonographers Other:
8. How many ultrasound scanning stations do you use at your facility? One Two Three More than Three
9. What type of ultrasound equipment do you use in your laboratory?
10. What type of ultrasound is performed in your laboratory?
Abdomen:
Superficial Structures:
Obstetric:
Gynecology:
Vascular:
Echo: