Physician Introductory Questionnaire

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Please answer the following questions about your practice, physician, fees, services and access details. You can provide as much detail as you are comfortable with.

If you feel there is additional information we should know (i.e. practice has more than one physician, practice offers services not listed here, etc.), please use the additional comments box at the end of each section to let us know. When finished click the Submit button.

Thank you.

Email *

Practice Name:

Practice Address, City State ZIP:

Practice Phone:

Practice email:

Practice Website:

Additional Comments (optional)

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