Physician Survey
Please note that all fields followed by an asterisk must be filled in.
Please take a few minutes to complete this survey and we will send you a StarBucks gift card as our way of saying thanks!
The top 3 practice problems that frequently keeps me awake at night are ...
Three things I believe are the key to a successful practice ...
The item(s) that create the most anxiety / tension between me and my practice manager are...
Key factors I consider critical in establishing and maintaining a productive working relationship with my practice manager include...
How much time per week do you personally spend in thinking / planning for the future of your practice?
How much time per week do you spend planning with your practice manager?
I belong to the following local / national associations...
The biggest benefits I get from my association(s) are...
In terms of professional improvement, what key skills would you like to learn?
What additional skills would you like for your practice manager to learn / possess?
What additional revenue strategies have you evaluated within the past 6 months?
What additional revenue programs have you implemented within the past 6 months?
What additional revenue programs are you planning to implement within the next 6 months?
Do you use now, or have you ever used a personal / business coach?
What is / was most beneficial from your coaching relationship?
What price per month did you pay for coaching?
How do you believe you (your practice) might benefit from having a coach?
What price per month would seem reasonable for email / phone access to a coach?
Would you be interested in becoming a coach?
When you GOOGLE, what business topic(s) are you most likely to search for?
Thank you very much for responding to the above questions. Please provide any other comments that yout think might help you and / or your peers achieve practice success ...
Please submit your contact information below and we will give you a StarBucks Gift Card.
First Name*
First Name*
Last Name*
Last Name*
E-mail Address*
E-mail Address*
Street Address*
Street Address*
City*
City*
State/Prov*
State/Prov*
Zip/Postal Code*
Zip/Postal Code*
Business Phone*
Business Phone*
Practice Specialty
Number of Physicians
Average Numbers of Patients per Day
Number of Practice Employees
