This survey will help provide names of good doctors 
with experience in Treating CNSV.
Please only provide the names of good doctors.  
We are hoping to get at least one good doctor for each state.
This will help people who cannot fly or travel too far
to be able to see a good doctor.
(Use 'TAB' key to navigate this form.  
   Pressing 'ENTER' will send the form.)

Enter Doctor's Information:
    
  First Name:

   Last name:

 Affiliation:

Select doctor's specialty:
              Neurologist
              Rheumatologist
              Primary Care Physician
              Neuropsychologist
              Psychiatrist
              Other

Telephone number with area code:

      Fax number with area code:

        Doctor's E-Mail address:

Address:
  Line 1:

  Line 2:

    City:         State:XXALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip code:

Please rate this doctor on the following criteria:
    (N/A= Not Applicable, 1=poor, 2=fair, 3=good, 4=above average, 5=excellent)

Experience:
Experience with Central Nervous System Vasculitis:
           N/A12345
Has treated CNSV before:
           N/A12345
Knowledge of treatment side effects and how to mitigate them:
           N/A12345
Familiarity with all treatment options:
           N/A12345
Explanation of treatment plan and options:
           N/A12345

Manner:
Bedside manner:
           N/A12345
Offers pallative care:
           N/A12345
Allows time for questions and answers:
           N/A12345
Willingness to work with other doctors/specialists:
           N/A12345

Office:
Ease of accesibility:
           N/A12345
Parking:
           N/A12345
Waiting areas:
           N/A12345

Office Staff:
On Time:
           N/A12345
Friendliness:
           N/A12345

Enter additional comments about this doctor:
(1000 characters max)
     None

Enter an E-Mail address if you would like others
to be able to contact you regarding this Doctor:

   
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