| Name:* |
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Address:*
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Your Phone Number:*
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| What kind of physician are you looking for?: |
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| What specific preferences do you have for your physician? |
Male |
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Female |
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Younger |
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Experienced |
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Will Use a Nurse Practitioner |
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Do Not Want to Use a Nurse Practitioner |
| Geographic Location Preference: |
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| Accessibility Requirements? Some of our offices you can park right outside the door, others require a walk to a common building. Do you have a preference? Tell us about any physical limitations for access. |
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| My main concern that I would like to see treated is: |
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| Check all conditions that you currently need help to manage. Check all that apply: |
| Diabetes |
Blood Pressure |
| Arthritis |
Cancer Diagnosis |
| Heart Disease Diagnosis |
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| For payment I will be using: |
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| As the patient, you are responsible for verifcation of participating providers allowed on your panel. |
| Best time to contact back with questions or suggestions between the hours of 8-5 Monday-Friday? |
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