Dr Issues

General Information Name of doctor: ____________________________________________________________

________________________ Name of physical exertion: ____________________________________________________________

______________________ Location: ____________________________________________________________

_____________________________ Phone: ____________________________________________________________

_______________________________ How did you hear of this doctor? ____________________________________________________________

___________ ____________________________________________________________

_____________________________________ Your health indemnification company: ____________________________________________________________

__________
About the give

1. Do you take my insurance?..................................... Y / N 2. Is this a solo or group practice? ___________________ If solo, who covers when the doctor isnt available? ___ ___________________________________________ ___________________________________________ If group, how often will we see otherwise doctors in the practice? ____________________________________ ___________________________________________ ___________________________________________ 3. How many years has the doctor been in practice?



____ ______________________________________________ ______________________________________________ 4. Does the doctor have any subspecialties? __________ ______________________________________________ 5. What are the powerfulness hours? ______________________ ______________________________________________ ______________________________________________ 6. What evening or weekend hours are available? ______ ______________________________________________ ______________________________________________ 7. atomic number 18 calls for routine/non-emergency questions encouraged? ___________________________________ ______________________________________________ ______________________________________________

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