Please fill in all fields marked with a *
	Degree	MDDORNMSNBS PharmacyPharmDTechnicianOther
	Specialty
	City
	State
	Country
	Email optional
	Yearly Base Income or Net Income
	Yearly Bonuses
	Years in Practice
	Number of full time physicians in your group
	Liability Insurance Percent and Dollar Increase in 2003
	Liability Insurance Percent and Dollar Increase in 2004
	How many physicians do you suspect will retire or relocate from your group
	What do you recommend to help most quickly solve the insurance dilemmas
	What do you recommend to help best solve the managed care dilemmas
	Rate your level of frustration with managed care	1 No Frustration2345678910 Highest Frustration
	Additional Comments and Suggestions