Clinical Trial Interest Form Name * First Name Last Name What is your Clinic/Practice name? * What is your Provider name? * How many total locations does your clinic/practice have? * Do any physicians, nurse practitioners, or physician assistants rotate from clinic to clinic? (If you only have one location, please select no.) * Yes No Where is your main clinic located (address)? * Address 1 Address 2 City State/Province Zip/Postal Code Country What phone number should we use to contact you about the clinical trial? * (###) ### #### Contact Email * What is the best day(s) of week to contact you about the clinical trial? Monday Tuesday Wednesday Thursday Friday What is the best time(s) of day to contact you about the clinical trial? 7am-9am 9am-11am 11am-1pm 1pm-3pm 3pm-5pm 5pm-7pm Your clinic mainly specializes in: Pain management Physical medicine and rehabilitation Orthopedic medicine Family medicine Addiction medicine Other (list below) How many physicians on staff have DEA certification to prescribe opioids? * How many physicians assistants on staff are authorized to prescribe opioids? * How many nurse practitioners on staff are authorized to prescribe opioids? * How many total physicians/physician assistants/nurse practitioners on staff have at least 10 patients being prescribed opioids for non-cancer/non-end-of-life pain on their roster? * Approximately what percentage of the patients in your clinic are on opioid therapy? <10% 10-25% 26-50% 51-75% >75% Thank you! We’ll be in contact soon.
