Employed Physician Practice Survey

Employed Physician Practice Survey

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Date Survey Prepared

Physician full name*

First Last

Mobile phone number*

Preferred email address*

Practice name*

Practice address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Practice phone number*

1) Please list the number of active patients you have seen in the time periods below. Note: please exclude patients seen while covering for another physician or one-time only

a. 18 months*

b. 24 months*

2) How many patients do you see per day?

3) Please list the top 3-5 zip codes where your patients reside*

4) Approximate percentage breakdown of patient ages:

a. 0-16*

Please enter a number from 0 to 100.

b. 17-26*

Please enter a number from 0 to 100.

c. 27-44*

Please enter a number from 0 to 100.

d. 45-54*

Please enter a number from 0 to 100.

e. 55-64*

Please enter a number from 0 to 100.

f. 65+*

Please enter a number from 0 to 100.

Total percentage entered

5) What is your percentage breakdown of practice panel insurance?

a. Medicare*

Please enter a number from 0 to 100.

b. Medicaid*

Please enter a number from 0 to 100.

c. HMO*

Please enter a number from 0 to 100.

d. PPO*

Please enter a number from 0 to 100.

e. Self-pay / other*

Please enter a number from 0 to 100.

Total percentage entered

6) What was your pre-tax income for the years below?

a. 2024*

b. 2025 to date*

7) How far out are you booked for routine appointments?*

8) Are you currently accepting new patients?*

Yes

No