Would you be interested in joining a coalition of chronic pain providers?

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* 1. Would you be interested in joining a coalition of chronic pain providers?

What is most important for you to gain from participating in this coalition?
On a scale from 1-7, with 1 being the most important:

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* 2. What is most important for you to gain from participating in this coalition?
On a scale from 1-7, with 1 being the most important:

If you chose OTHER, please describe:

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* 3. If you chose OTHER, please describe:

Would you attend an in-person meeting of the Coalition? (Choose all that apply)

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* 4. Would you attend an in-person meeting of the Coalition? (Choose all that apply)

What is your preference(s) for meeting:

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* 5. What is your preference(s) for meeting:

Would you like us to follow-up with you concerning your participation in the Coalition?

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* 6. Would you like us to follow-up with you concerning your participation in the Coalition?

If YES, please provide contact details including name, email and phone:

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* 7. If YES, please provide contact details including name, email and phone:

Would you be interested in participating in a Health Care Fair in October?

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* 8. Would you be interested in participating in a Health Care Fair in October?

Please write in your area of expertise and credentials:

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* 9. Please write in your area of expertise and credentials:

Comments/Suggestions:

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* 10. Comments/Suggestions:

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