*Name of Provider(Required.)

Email Address

Telephone

*Are phone calls attended to promptly and courteously?(Required.)

Yes

No

*Are you satisfied with the way your appointments are scheduled?(Required.)

Yes

No

*Are our locations and office hours convenient for your patients?(Required.)

Yes

No

*Is the requisition easy to follow?(Required.)

Yes

No

Are reports received in a timely manner?

Yes

No

*Are reports concise and accurate?(Required.)

Yes

No

*Would you recommend Clear to other referring providers?(Required.)

Yes

No

*How likely are you to continue to send your patients to Clear?(Required.)

Likely

Possible

Unsure

Not Likely

How did you refer your patients to us?

Requisition Pad

EMR

Fax

Ocean eReferral