Stay At Home Docs

Intake Survey (page 1/2)

Welcome to Stay At Home Docs! This survey gives us an opportunity to get to know you professionally and personally.
Name*

First NameLast Name
Phone:*
(555) 123-4567 Format: (000) 000-0000.
E-mail:*
NPI*
US-licensed Physicians only
How did you hear about Stay At Home Docs?
Tell us about yourself!
I am a What's your Specialty?, and I have been in practice      years.
I currently work    hours and days per week.

I would like to work hours per week in my own Virtual Private Practice, and see patients in  states.

I am ready to start working on my new practice in the next, and want to start seeing patients onDate of Practice Launch.
Locum TenensUrgent CareTelemedicine Private PracticeTelemedicine Agency / ContractorInpatient Direct HireInpatient Group PracticeOutpatient Solo PracticeOutpatient Group PracticeResident / HousestaffTravel / International / HumanitarianMilitary / VA / GovernmentAcademic / Non-ClinicalNon-Clinical Consulting or ResearchOther

On a 1-10 scale, how committed are you to launching your Virtual Private Practice in the next 90 days?

	1	2	3	4	5	6	7	8	9	10

1 is I'm Curious, 10 is I'm Fully Committed

What are your passions outside of medicine?
I don't know how to get startedThe process is confusing and intimidatingI've already started the process, but I'm stuckI don't know if it will be profitableI'm too busy with my current workI need a project manager and accountability partnerI've never run my own businessI need to develop a business plan and revenue modelInitial launch costs and monthly operating expensesI don't know how patients will find my practiceI don't have a practice name or product brandI don't know how to do my own billing and claimsI'm not ready to leave my current practiceI need more education on HIPAA compliance and cybersecurityPersonal and family healthI'm experiencing burnout, and I'm not sure if Telemedicine is a good or bad idea for meOther

Intake Survey (page 1/2)