NEW CMT Patient Inquiry

NOTE: If You're A Physician & Would Like To Be Listed On The National Directory, CLICK HERE for More Information ... All Others, Please complete the form below to view a list of physicians and healthcare providers in your area. Thank you. Your information is kept private and will not be sold or utilized for any spam or advertisements. We use this info., solely to assist you in connecting you/your family with the right private/concierge-style doctor near you and provide you with educational information via email.

Your Email Address *

example@example.com

"If Your Doctor Went Out of Business, How Much/Little Would You Care?" *

Not At All. Glad They're Gone. I Wanted A New One Anyway. It Would Be Inconvenient But I Didn't Have A Relationship/Care Either Way With Physician. Call The Mayor! Save This Business! They Would Absolutely Be Missed! Don't Let This Medical Office Close! We Have To Save It!

How'd You Find Us? *

What is most important to you? (Top Choice) *

Convenience Finding A Doctor I Like/Trust Cost

Do you currently have unresolved medical debt from bills within the past 12-mos. *

No Yes, but I can afford to pay them. Yes, and I don't understand the numbers. Yes, and some things are being denied and need to be appealed.

Do you TRUST Your PCPs Opinion? On a scale of 1 to 5 (1 Not at All; 3 Sort of; 5 Great!), Rank Your Level of Trust in Your Current PCP. *

	1	2	3	4	5

1 is Worst, 5 is Best

Generation/Age Type *

Do you Actually LIKE Your Doctor? On a scale of 1 to 5 (1 Not at All; 3 Just Okay or; 5 Great!), Rank Your Level of Interaction with Your Current Doctor. *

	1	2	3	4	5

1 is Worst, 5 is Best

How important is it to you that your Concierge Medicine Doctor accept insurance or participate in Medicare? (1= not important at all; 5=Extremely important) *

	1	2	3	4	5

1 is Worst, 5 is Best

When applicable, do you want your Concierge Doctor to file claims with your insurance or Medicare? *

How Important Is Customer Service, Timeliness and Friendly Hospitality To You In Your NEXT Doctor? (1 Not Important At All; 3 Important; 5 Extremely Important/Must Have) *

If Your Doctor Went Out of Business Tomorrow, How Much/Little Would You Care? *

A lot of internal medicine doctors are understandably quite busy. If you had the option, would you rather visit an ... *

D.O. (Doctor of Osteopathic Medicine) N.P. (Nurse Practitioner) P.A. (Physician Assistant) R.N. (Registered Nurse) M.D. (Medical Doctor)

Why Are You Leaving Your Current Doctor's Office? (Check All that Apply) *

He/She Asks Me Less Than 5 Questions Convenience/Long Wait Times The Staff Is Difficult To Work With I Feel Like A Number He/She Spends Less Than 15-Min. w/ me per visit. Insurance Incompatibility Not a Medicare Participating Provider

Rate How Important Air Quality is to you in your Doctor's Office (1 not at all; 5 Very Important)

Is The Office/Physician You Are Leaving a Concierge Doctor? *

If you chose NP, PA or RN, please explain why.

Why are you searching for a Concierge Doctor?

Your City *

State *

Zip Code

Do You Need Surgery As Well? Are you searching for a Surgeon for you or someone else? *

Yes, For Myself. Yes, For Someone Else. No, not at this time.

WHY DO WE ASK FOR THIS INFORMATION?

Once you've completed the form below, you will be redirected back to Concierge Medicine Today's Complete Physician Directory. IF YOU ARE UNABLE TO LOCATE A PHYSICIAN CURRENTLY ACCEPTING PATIENTS and LISTED IN OUR NATIONAL DIRECTORY, we use this information to help connect you with a physician not listed on our directory, if necessary. Should you require a more exhaustive search, please contact us directly [editor@conciergemedicinetoday.com] and we may be able to locate a physician in your area not listed on our Directory at this time. Thank you!

Misc. Comments