Community Physician Orientation Questionnaire

About Your Practice

We hope you had an opportunity to join us at one of our EpicEdge Community Physician Orientation sessions held recently. As mentioned in these sessions, the following questionnaire will help us in outlining the best approach for data conversions, IT support, and much more.

If you would kindly complete this at your earliest convenience, we would greatly appreciate it.

Question Title

* 1. Contact Information

Name *

Name of Practice *

Address

Address 2

City/Town *

State/Province

ZIP/Postal Code

Email Address *

Phone Number

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* 2. How many physicians are in your practice (include partial FTE's)?

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* 3. How many physician assistants or nurse practitioners are in your practice (include partial FTE's)?

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* 4. How many physical or occupational therapists are in your practice (include partial FTE's)?

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* 5. How many other advance practice professionals are in your practice (include partial FTE's)?

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* 6. What type of practice do you have?

Primary Care

Specialty

Combination Primary Care and Specialty

If Specialty (please specify)

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* 7. How many patient visits does your practice conduct annually (include visits by partial FTE's and mid-level providers)?

Less than 3,000

3,000-10,000

10,000-25,000

25,000-50,000

More than 50,000