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Provider Concierge Enrollment Form
Fields marked with an asterisk (
*
) are required
Name
*
First
Last
Mobile Number
*
I am a:
*
Doctor
Staff nurse
Advanced Practice Nurse (APN)
Midwife
Social worker
My specialty is:
*
OBGYN
Maternal fetal medicine
Behavioral health
Neonatologist
Family/general practitioner
Pediatrics
Not applicable
Please indicate the percentage of patients that you treat with Opioid Use Disorder (OUD).
*
None
1 - 10%
10 - 25%
Over 25%
Don't know, this is not something I discuss with my patients.
Do you have an interest in augmenting your current care plan for treating patients with OUD?
*
Yes
No
How confident are you treating people with OUD?
*
5 - Extremely confident
4 - Very confident
3 - Confident
2 - Relatively confident
1 - Not confident at all
How familiar are you with the effects of opioid medication withdrawal?
*
5 - Extremely familiar
4 - Very familiar
3 - Familiar
2 - Relatively familiar
1 - Not familiar at all
How confident are you in utilizing local resources for support services?
*
5 - Extremely confident
4 - Very confident
3 - Confident
2 - Relatively confident
1 - Not confident at all
Do you believe having an OUD Learning Management System will be helpful in your practice?
*
5 - Extremely helpful
4 - Very helpful
3 - Helpful
2 - Relatively helpful
1 - Not helpful at all
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