Are You a BTE Power User? Tell Us About Your Results!

Please tell us about your practice to be featured as a BTE Power User. Fill out some or all of the following fields to let us know about your clinical successes using BTE technology.

Name (as you want it to appear):

Title/Position (as you want it to appear):

Professional Affiliations: (APTA, AOTA, NATA, etc):

Email Address (required - so that we can contact you):

Name of Facility (as you want it to appear):

City:

State/Province:

Country (if outside the US):

Facility Type (ex. Private Practice, Hospital Outpatient, etc):

Number of Facilities in Your Provider Network: (are you part of a chain?)

Size of Facility (approximate square feet/meters):

Estimated Client Volume Annually (new patients):

Number of Licensed Clinicians:

List Some Other Specialty Programs Taking Place at Your Clinic :

Which BTE System are you using to accomplish great results?
Primus Simulator EvalTech / ER MCU TechTrainer Evaluator

How many years have you had your BTE System?

Is your BTE System Rented or Purchased?
Rented Purchased

Were there obstacles or barriers to your decision to purchase or rent your BTE System? If yes- what where they? How were they overcome?

What led you to purchase/rent your BTE System?

What is your favorite hardware/software feature?

Describe your general experience with BTE Training and Service.

Clinical Outcomes (generalized impact of technology on clinical practice, brief client success story, etc.)

Financial Success (patient volume increase, return on investment, service marketability)

Clinical Quality (client satisfaction, adherence to appointment schedules)

What would your advice be to a clinician considering the BTE System you use?

Agreement

Release

For good and valuable consideration, receipt of which is hereby acknowledged, I hereby consent to the use, publication, and copyright, from time to time in the future, by the Licensed Parties identified below, in domestic and /or foreign markets, in the form attached or as edited by them, of the attached testimonial, including the photograph of myself, (collectively, the “testimonial”), alone or in conjunction with other photographs and/or testimonials for advertising, publicity, commercial or other business purposes of any Licensed Party.

The Licensed Parties include BTE Technologies Inc., and any of its associated or affiliated companies (including any distributors, resellers, retailers, representatives, and the like), their respective directors, officers, agents, employees and customers, and any appointed advertising agencies of any of them, and the directors, officers, agents and employees of such advertising agencies. I hereby release all of the Licensed Parties from all claims of every kind on account of such use, publication, or copyright. I agree that all photographs of me used by the Licensed Parties are owned by them. I agree that no advertisement or other material need be submitted to me for any further approval. I warrant and represent that this document does not conflict with any existing commitment on my part.

Consent of Entity

The entity identified in the testimonial referred to in the above Release hereby consents to the use of the name of the entity in, and in connection with the use, publication, and copyright, on the terms and conditions set forth above, of, such testimonial.

I have fully read and agree to the terms outlined in the preceeding statement (Release and Consent of Entity)