Nomination Questionnaire for the General Public
Throughout history, Physicians have been instrumental in driving progress in a wide range of areas in our healthcare culture. In modern times, the presence and recognition of Physicians in leadership roles have significantly increased across many specialties, including academics, leading new business endeavors, involvement in hospital leadership, leading advancements in healthcare technology, creating entrepreneurial opportunities, leading the conversation about healthcare and A.I., and more. I understand that my submission may be used by Concierge Medicine Today, LLC to contact the nominated Physician and recognize that completion and submission of this form is no guarantee of their selection. Please do not submit more than one Physician nominee per application, do not share personal information without their explicit consent and do not submit the same nominee more than once.
Full Name of Physician You Are Nominating:
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First Name
Last Name
City and State of Physician's Practice/Current Business (City/State)
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Web Site and/or LinkedIn Profile of the Physician's Practice/Business
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Your Name/Name of Nominating Person or Organization
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Your professional history with this Physician?
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THREE CRITERION USED BY THE EDITOR'S AT CONCIERGE MEDICINE TODAY TO MAKE THEIR FINAL SELECTIONS
The Practice of Self-leadership involves understanding oneself, managing emotions and behaviors, setting goals, making decisions, and being proactive, self-disciplined, and adaptable; The Practice of Risk Taking involves making decisions or engaging in activities with uncertain outcomes. It is essential for personal and professional growth; and The Practice of Delegation empowers leaders to entrust tasks and responsibilities to others, harnessing the diverse skills and talents within their teams for greater productivity.
Why do you believe this Physician "Nominee" should be chosen?
The recognized Physician leaders should exemplify courage, innovation, fresh perspectives, and unwavering determination in their respective fields and organizations. They play a crucial role in inspiring future generations of Physician leaders, emphasizing that self-leadership, risk-taking, delegation, and courage are essential qualities for the next generation of Physician leaders. Please write a few words about why you feel their leadership is important to you in concierge medicine and/or at your respective organization/practice or position of influence or previous professional experience with this Physician.
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Disclaimers, Terms and Conditions
By submitting this information below, Concierge Medicine Today may, in the future, use criteria to develop trends or future leadership criteria for future Concierge Medicine Today content. You understand and acknowledge that the information you submit/share will be used by Concierge Medicine Today LLC to select the "Top Physician Leaders [List] in Concierge Medicine for 2025" and release Concierge Medicine Today, LLC, its agents and representatives from any and all consequences or claims that should arise from the inclusion of your name, practice and title on this list. Please note that a submission is not a guarantee of acceptance. Only a small number of applicants will ultimately be chosen for the distinction/recognition by Concierge Medicine Today. Concierge Medicine Today may remove personal information from the information you submit with specific Concierge Medicine Today advisors to help vet nominations before final selection(s) are made. Nominees are evaluated based on their understanding of themselves, ability to manage emotions and behaviors, goal-setting, decision-making, proactivity, self-discipline, adaptability, willingness to engage in activities with uncertain outcomes, and empowerment of others through task delegation for greater productivity and may be contacted directly to complete the process. Please note that final selections will not be announced until January 15, 2025, at the industry's trade publication, www.ConciergeMedicineToday.org.
Yes, I accept the Disclaimers, Terms and Conditions stated above. Please note, any/all applicants or submissions who do not agree to the terms and conditions will not be considered part of the selection process.
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Yes, of course!
Submit
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