Patient Telemedicine Interest Survey

Question Title

* 1. Tell us about yourself.

Name:

The best way to reach me is

Phone number

E-mail Address

Question Title

* 2. What city and state are you from?

City

State

Question Title

* 3. What conditions or diagnosis would you be interested in receiving treatment via telemedicine.

Question Title

* 4. If you didn't receive care via telemedicine, how would you receive the care you need?

Primary Care Provider

Urgent Care

Emergency Room

Specialist Visit

Wouldn't receive care

Other (please specify)

Question Title

* 5. What concerns you most about receiving healthcare via telemedicine?

Question Title

* 6. Which of the following is your primary insurance coverage through?

Medicare

Medicaid

Private Insurance

Other (please specify)