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Interested in having a risk assessment?
Please tell us a little bit about you and how to respond to your request.
First, what's your name?
First Name
Last Name
Suffix
Which of the following best describes you:
MD/DO
PA/RN/APN/CNM/CRNA
Other staff member
Office Manager
Clinic Administrator
Risk Manager
ISMIE Producer
Are you the person we should speak with to handle the details of setting up this assessment?
Yes
No
I'm not sure
Who should we speak with to set up this assessment?
First Name
Last Name
What phone number should we use when following up on this request?
Please be sure to include your extension, if relevant.
Where should any email correspondence be sent?
This may include scheduling correspondence, confirmation letters, assessment results, etc.
How would you prefer we contact you?
Phone
Email
Please tell us a little bit about your practice.
What is the name of the practice?
Where is the practice located?
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Does the practice have other locations?
Yes
No
How many locations does the practice have?
Does the practice use an electronic medical record system?
Yes
No
How many clinicians (MDs, DOs, PAs, APNs, etc.) do you anticipate participating in this assessment?
Finally, are any of the clinicians to be assessed:
Anesthesiologists
Emergency Medicine Specialists
Hospital-based Specialists
Nursing Home Specialists
Pathologists
Radiologists
Urgent Care Specialists
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