Best Doctors Questionnairericklehe@gmail.com2023-01-24T19:49:00+00:00

Best Doctors

Qualification Questionnaire

Learn about the Best Doctors program

Doctor Information

Upon qualification, this information will appear on your public profile.

First Name *

Last Name *

Degree Abbreviations *

Type of Practice *

Business Phone *

Physician Gender *

Business Street Address

City *

State *

Zip *

Website

Business email *

Contact Details

This information is for internal purposes, to contact you regarding your qualification and profile.

Doctor’s Email *

Doctor’s Phone *

Secondary Contact Name

Secondary Email

Secondary Phone

Certifications & Affiliations

This information may appear on your public profile. Upon qualification, you may request to omit fields.

What is your primary specialty *

How many years have you been practicing medicine as a doctor? *

Education (please list one school or fellowship per line):

In which states are you licensed to practice? *

Please list hospital affiliations (one hospital per line):

Are you board-certified? *

YES

List your board certifications:

Do you take insurance?

YES

What insurance do you accept? (please list one insurance per line):

Please list any medical or professional affiliations (one per line):

Patient Reviews:

Disclosures

This information is for internal purposes only.

Do you have any current restrictions on your medical license? *

YES

If you have any current restrictions on your license, please elaborate:

Do you have any current disciplinary actions/suits against you? *

YES

If you have any disciplinary actions/lawsuits against you please provide an explanation below.

I consent that the survey information provided above is accurate and may be used by WomenCertified Inc. on the Women’s Choice Award website. Doctor and secondary contact email and phone details provided will not be made public on the website or used for any promotional purposes. Applicants may not use the Women’s Choice Award award logo (seal) without licensing rights. For more information contact info@womenschoiceaward.com.

Consent *

Thank you for your interest. We will get back to you shortly!

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(Optional) To complete your profile, we recommend sending your headshot to Julia at jragland@womenschoiceaward.com