Survey

* indicates required field

First Name:*

Last Name:*

Area Code And Phone Number:*

What Is Your Medical Specialty?*

Email:*

Street Address:*

Street Address 2:*

City:*

State:*

Zip:*

How Many Years Have You Been In Practice?*

What Is The Size Of Your Patient Panel?*

How Many Patients Do You See Per Day?*

How Many Days Per Week Do You Treat Patients?*

What Percentage Of Your Practice Is 40+ Years Or Older?*

What Percentage Of Your Practice Is MEDICARE Eligible?*

Are You Married? (Why do we ask? See below.)*

Current Environment: Solo or Group Practice?*

If Group, how many doctors work in the practice?*

How Would You Classify The Socio-Economic Profile Of Your Patients?*

Working Class / Government Subsidized
Lower Middle Class
Middle Class / Affluent
Upper Middle Class To Very Wealthy

Name Of Current Billing Software (If Applicable):*

Name Of Current EMR Software (If Applicable):*

How Long Have You Been Investigating Concierge Medical Practices?*

Under 3 Months
3-6 Months
6-12 Months
12+ Months

If You Were To Transition To A Concierge Medical Practice, When Would You Anticipate Moving Forward?*

Under 3 Months
3-6 Months
6-12 Months
12+ Months

What Motivates Your Interest In This Industry? (Check All That Apply)*

Become Less Reliant On Insurance/Managed Care
Lifestyle/Work-Life Balance
Financial
Desire To Deliver Higher Quality Healthcare
Desire To Work With Compliant Patients That Value Their Doctor

What Other Practice Models Are or Have You Considered?*

Cash Practice
Work For Large Group
Hospitalist
Status Quo
Retire Early

Message:*

Survey

Please fill out this survey form below.

Stephen, our PersonalMD Director will follow up with a thorough analysis of why your practice may or may not be a good fit at this time to transition to a concierge medical practice.

If you have questions, please contact our PersonalMD Director, Stephen, at 702-751-2904.