This form has not changed, we are just collecting information on the users submitting the data in case we need to contact you for more information. 

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* 1. What is your First and Last name?

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* 2. What is your contact email?

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* 3. What is your contact phone number?

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* 4. What is the name of your practice?

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* 5. What physician and location were you connected to?

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* 6. Describe the Appointment

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* 7. Who was the payer for this visit?

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