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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
Jason Croskrey, MD
Jeffrey Young, OD
Jena A. Meyer, 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
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
Yong Kwon, OD
Date of Conversation
MM slash DD slash YYYY
Method of Conversation
(Required)
Text
Email
In person
Phone call
CE Event
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.
Hidden
New physician introduction
Hidden
Patient Care
Hidden
Area(s) of Concern
Hidden
Upcoming CE event
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
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