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Registration of interest in Group Therapeutics
Email
*
First Name
*
Last Name
*
Phone Number
*
Company or practice name
*
NPI number
Street address
*
City
State/Region
Website URL
*
Facebook URL
Twitter URL
LinkedIn URL
Instagram URL
How did you hear about us?
Word of mouth
Social Media
LinkedIn
Google search
Other
What is the total number of active patients in your practice?
*
How many outpatient visits do you have per month?
*
Please Select
50-100
100-500
500-1000
1000+
Area of specialty
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Gastroenterology
Nephrology
Primary Care
Rheumatology
Obstetrics and Gynecology
Pain Medicine
Cardiology
Pediatrics
Endocrinology
Dermatology
Oncology
Hematology
Infectious Disease
Anesthesiology
Family Medicine
Allergy and Immunology
Mental Health
Physiotherapy
Other Specialty
How many licensed providers are currently working in your practice?
*
How many non-licensed staff members work in your practice?
*
What type of payment methods do you accept in your practice?
*
Insurance
Cash
Monthly subscription
Concierge
Financing
How do you typically receive patient referrals from specialists or other healthcare providers?
Direct communication
EHR Referral
Referral Forms
Care Coordination Teams
Fax
What are your current patient engagement strategies?
Social media
Digital health app
Patient portal
Wellness Coaching
Support Groups
Feedback and Surveys
Follow-up calls and reminders
Other engagement methods
What programs are you interested in?
*
Group Visits
Chronic Care Management
Remote Patient Monitoring
What are your goals for implementing Group Therapeutics services?
What outcomes do you hope to achieve for your patients and your practice through this service?
Would you like to share anything else?
Persona
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