BARRIGEL COE FORM

Leaders in Patient Education

Congratulations on your Barrigel™ Center of Excellence Designation! Please complete the form below, as we’ll need this information in order to provide you with your official recognition of Barrigel COE status and build your personalized Barrigel Physician Finder profile page.

Click here for an example COE Physician Finder profile page.

PERSONALIZED RECOGNITION
OF COE DESIGNATION

1.Please select the personalized recognition format(s) that you’d like for your office
(select all that are desired):

Personalized Framed Certificate

11x14” frame

Personalized Front Office Poster

24x36”

2.Enter your exact name and titling as you’d like them to appear on these items (e.g., John Smith, MD, FACS):

3.Provide your practice website URL (specific profile page if preferred) for your listing:

PERSONALIZED PHYSICIAN
FINDER PAGE

1.Please provide the following information for development of your personalized page on the Barrigel Physician Finder.

Please provide a short bio (CV or preferred website bio):

2.Upload your headshot here (accepted file types: png, jpeg):

Maximum individual file size 50M

Clear

IMAGE UPLOAD

or just drag and drop files here.

Preview

3.Provide the email address where you’d like “Request Appointment” form submissions to be sent.

Note: If you have more than one location active on the Barrigel Physician Finder, this email address will apply to all locations; please ensure the email address you provide will work for requests coming through any of your locations.

“Request Appointment” recipient email address:

By checking this box, I opt into the Barrigel Center of Excellence Program and consent to receive recognition for completing advanced procedure technique training and all required program criteria. I understand my designation as a Center of Excellence will be reviewed on an annual basis and that I must maintain all required criteria to be eligible for annual status renewal.

Regarding the Barrigel Physician Finder, I understand that Palette Life Sciences reserves the right to remove and/or exclude any physician from the Physician Finder, with or without COE Program designation, immediately and without notice in its sole discretion in the event that Palette Life Sciences becomes aware of (i) any alleged or suspected fraud or abuse or violation of law, arising out of any activity involving the physician, (ii) any alleged or suspected violations of any federal or state health care program requirements by the physician, (iii) any threatened, proposed, or actual revocation of license/certification, suspension, exclusion, or debarment of the physician, (iv) any subpoena, legal process, civil investigative demand, discovery request, or similar request for information involving the physician, and/or (v) any facts, allegations or situations of a similar nature.

GET STARTED AS A BARRIGEL CENTER OF EXCELLENCE

Leaders in Patient Education

PERSONALIZED RECOGNITION OF COE DESIGNATION

PERSONALIZED PHYSICIANFINDER PAGE

GET STARTED AS A BARRIGEL
CENTER OF EXCELLENCE

PERSONALIZED RECOGNITION
OF COE DESIGNATION

PERSONALIZED PHYSICIAN
FINDER PAGE