Exit this survey
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1
. Please fill out the information below so that we have your correct and current information.
Please fill out the information below so that we have your correct and current information.
Name
Home Address
City/Town
State
ZIP
Cell Phone
Email Address
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2
. Please fill out the information for your primary practice location.
Please fill out the information for your primary practice location.
Primary Office Name
Address
City/Town
State
ZIP
Office Phone Number
License Number
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3
. For your primary practice location check all that apply to you for this location.
For your primary practice location check all that apply to you for this location.
Solo owner of a practice with a dispensary
Solo owner of a practice without a dispensary
Owner in a partnership practice with a dispensary
Owner in a partnership practice with out a dispensary
The employer of other ODs
Employed by another OD
Employed by an MD
Employed by a clinic or other facility
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4
. Please fill in all boxes that apply for this location.
Please fill in all boxes that apply for this location.
Name of your partners
Name of your employer
Names of your employed ODs
Staff size excluding doctors for this location
Numbers of hours you work at this office per week
If the office is adjacent to an optical, please name the business
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5
. Do you have an additional practice location?
Do you have an additional practice location?
Yes
No
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