0 Referral Partner Application Referral Partner Application About the PrescribeWell Referral Partner Program: PrescribeWell offers an obesity intervention (OBI) solution that allows the staff at a practice, hospital, or other healthcare organization to effectively monitor and treat obese patients who need to lose weight through behavior modification (dietary and activity changes) instead of surgical or other more intense means. PrescribeWell is a software-as-a-service (SaaS) system that compliments the leading EMRs (electronic medical record systems). We welcome established, technically competent Referral Partners to apply to become part of our community. If you are authorized to enter into a contractual relationship for your company, please begin. All information shared as part of this application will be kept in confidence. Step 1 of 4 25% Part 1 – Contact infoName First Last Job TitleEmail Business NameCell PhoneWork PhoneOffice address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Business web address Sales staff full-timeYear establishedOther Healthcare IT products/services/solutions that you represent What interests you in representing PrescribeWell’s OBI (obesity intervention) solution? Part 2 – About Your CustomersPlease pick a current client organization you can use as a model in answering the questions below.Please list the 3 biggest needs/concerns that they have today with regards to treating obese patients What EMR does this organization use?NextGenEpicAllscriptseClinicalWorks Part 3 – About Your Relationship with PrescribeWellPrescribeWell provides training and support to get you and your sales team up to speed.How soon would you be able to begin the virtual training?How many of your sales team would participate in the delivery?Are there any factors that would prevent you or your staff from succeeding with the training?Please list 3 business references belowNamePhoneemailCompanyRelationship If there is anything else you’d like us to know, please include it below. Part 4 – Thank youWe have received your application and will be in contact with you within 2 days to discuss further with you. Thank you again for your interest in representing PrescribeWell.