Office Survey

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TRACKING*

Name*

First Last

Clinic Address*

Street Address City State ZIP Code

Phone*

Fax*

Email*

Enter Email Confirm Email

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From which college did you graduate?*

In what year did you graduate?*

Techniques:*

Please check all that apply to your practice:

Other Techniques*

Practice Profiles:*

Please check all that apply to your practice:

Other Practice Profiles:*

Do you take your own X-rays?*

Do you perform your own laboratory studies?*

Procedures:*

Please specify the procedures you would allow the intern to perform in your office:

Other Procedures:*

Office Hours*

How many hours per week do you spend in the office?

Additional Office Information:

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Preceptorship Program
Office Survey