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Long COVID Care Provider Review Form
The purpose of this form is to provide a review or recommendation for a doctor (or other care provider) that has treated you as a long COVID patient.  The data will be added to a forthcoming website that will serve as a directory for people with long COVID who are seeking care. 

Consent Statement:
By submitting this form, you agree to have your review included on our website, which will serve as a directory for people with long COVID seeking care.
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Email *
What is the name of the care provider? *
What is their specialty (e.g. GP, neurologist, acupuncturist)?
 *
What is their gender? *
Where are they located (country, state, city)?
 *
Were you offered a virtual appointment?
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Do they accept health insurance?
Clear selection
Do they accept medicaid?
Clear selection
How easy was it to get an appointment?
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Approximately when did you last see this provider?
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Do they prescribe medication for long COVID symptoms?
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What long COVID symptoms have they treated you for?
 *
How would you rate this provider on a scale of 1 to 5? *
What other information about this provider would you like to share?
 *
What is your name? (Put "anonymous" if you would like to have your name left off the directory)
 *
Where would you like the $15 donation to be sent on your behalf? *
If Other, please enter below
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