Physicians Panel Survey

First Name *

Last Name *

Email *

1. Name of Physician: *

2. Field of Medicine/Practice * (Choose one)PediatricianFamily PracticeInternal MedicineOther

3. Contact Information for Physician: (Practice Name, Phone, Email, Address) *

4. How long have you known this physician? * (Choose one)<1 year1-3 years3-5 years5-10 years10+ years

5. Physician's Religion or Known Status * (Choose One)Known to be CatholicUnsure but respectful of Catholic beliefsAdvocates for treatment contrary to our beliefs