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Physician Outreach Form
Physician Outreach Form
Your Location:
(Required)
NWES - Bellevue
NWES - Seattle Northgate
NWES - Sequim
NWES - Smokey Point
NWES - Renton
NWES - Mount Vernon
NWES - Whatcom
EEP - Spokane Valley
EEP - Coeur d'Alene
Harman
Edmonds
Amara
MVEC
Your Name:
(Required)
Aaron A. Kuzin, MD
Agnes S. Huang, MD
Ali S. Mainayar, OD
Andrew S. Do, OD
Amandeep Buttar, OD
Ashlin Zarate, OD
Brett G. Bence, OD
Bethany B. Li, OD
Bruce D. Cameron, MD
Bruce E. Wietharn, MD
Bruce J. Ballon, MD
Casey Claypool, OD
Christopher W. Sturbaum, MD
Davina S. Kuhnline, OD
Emily A. Bucher, OD
Emily R. Freeman, OD
Ian P. Boydstun, DO
James R. Townley III, MD
Jamie Varghese, OD
Jason Croskrey, MD
Jeffrey Young, OD
Jena A. Meyer, OD
Jenna D.Hoiland, OD
Jennifer N. Bilek, OD
Jessica N. Couch, OD
Jillian E. Schnibben, OD
Justin L. Wright, OD
Kristi L. Bailey, MD
Landon J. Jones, OD
Laura S. Kearsley, MD
Leigh M. Gongaware, OD
Mark Kontos, MD
Max Psolka, MD
Michael R. Banitt, MD
Michael B. Wong, MD
Michelle N.Nguyen, MD
Monica N. Chan, OD
Natalia V. Bajenova, MD
Patricia M. Oh, OD
Paul B. Griggs, MD
Sarah E. Sandhaus, OD
Sarah P. Henderson, OD
Shikha Yadav, OD
Susan L. Hoki, MD
Werner Cadera, MD
Conv. Method/Special Consid
(Required)
Text
Email
In person
Phone call
CE Event
Lecture
Article
Media Interview
Marketing Video
CE Moderator
Leadership Position
Point Values
â–¼
Conv. Method
Points
Text
1
Email
1
In Person
3
Phone Call
1
CE Event
1
Special Consid.
Article
5
CE Moderator
5
Leadership Position
5
Lecture
5
Media Interview
5
Marketing Video
5
Hidden
Section Break
Date of Conversation
MM slash DD slash YYYY
Physician You Spoke With:
(Required)
First
Last
Practice Name:
(Required)
Have they referred to you before?
(Required)
Yes
No
Topic(s) Discussed:
(Required)
New physician introduction
Patient Care
Area(s) of Concern
Upcoming CE event
Other
Choose all that apply.
Other Topics
Please write a detailed account of your interaction
(Required)
Topics requiring follow-up
(Required)
Scheduling
Outcomes
Clinic Wait times
Transfer of Care
Other
None
Comments
Did your outreach representative help facilitate this interaction?
(Required)
Yes
No
Hidden
Lecture Fields
Lecture date
(Required)
MM slash DD slash YYYY
Lecture title
(Required)
Location (of Lecture)
(Required)
Association
(Required)
organization/group lecture
Lecture Comments
Hidden
Article Fields
Release date
(Required)
MM slash DD slash YYYY
Article Title
(Required)
Distribution
(Required)
where/how article was distributed
Article Comments
Hidden
Media Interview Fields
Recording date
(Required)
MM slash DD slash YYYY
Episode Title
(Required)
Content Discussed
(Required)
summary of topics
Association
(Required)
podcast series/organization
Media Interview Comments
Hidden
Marketing Video Fields
Production Date
(Required)
MM slash DD slash YYYY
Content Focus
(Required)
main subject/message
Specialty
(Required)
relevant specialty
Marketing Video Comments
Hidden
CE Moderator Fields
Event Date
(Required)
MM slash DD slash YYYY
Location (of Event)
(Required)
Association
(Required)
hosting organization
CE Moderator Comments
Hidden
Leadership Position Fields
Position title
(Required)
Association
(Required)
organization
Start Date
(Required)
MM slash DD slash YYYY
Ongoing
Select ongoing If no end date available.
Ongoing
End Date
MM slash DD slash YYYY
Leadership Position Comments
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