Recommend a Medical Professional

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Type of medical professional: *

Name of medical professional: *

Address of medical professional:

Phone number of medical professional: *

Hospital affiliation, if known:

How long and how often have you seen this medical professional? *

Does this medical professional explain information well? *

Yes

N/A

Does this medical professional listen well? *

Yes

N/A

Does this medical professional return calls in a timely manner? *

Yes

N/A

Does this medical professional order necessary tests? *

Yes

N/A

If you are comfortable with sharing the information, please let us know the type of surgeries or treatments you have received from this medical professional:

Please write here any further information you would like to share about this medical professional:

Your name: *

If you are willing to answer further questions about this medical professional, please list your contact information:

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