Recommend a Health Care Provider
Please use this form to enter information about health care providers that you would (or would not) recommend to other patients. Information you provide may be used to help other patients.
Provider's Name/Practice *
Physician or other type of health care provider
Your answer
Provider's Address/Phone *
Please enter as much as you know
Your answer
What is the provider's role in your treatment? *
Required
Provider's specialty *
May list more than one if relevent. Examples: primary care, infectious disease, sleep, physical therapy, chiropractor, etc.
Your answer
What were you seeking treatment for? *
Required
When did you first see this provider (approximate date)?
Your answer
When did you last see this provider (approximate date)?
Your answer
Please rate this provider's knowledge about the illness(es) *
(Specify which illness in the following question)
Required
The answer above applies to which illness(es)? *
Required
Would you recommend this provider to others? *
Your name *
Your name will not be associated with this provider information. We request it only because we may contact you if more detail is needed.
Your answer
Please enter phone or email. *
Your answer
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