Provider Telemedicine Interest Survey

Question Title

* 1. Tell us about yourself.

Name:

Specialty

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 willing to treat via telemedicine.

Question Title

* 4. What concerns you most about delivering healthcare via telemedicine?

Question Title

* 5. How soon would you like to get started?

Within the next 6 months

6 months to a year from now