Field Research, Inc.

	High Quality Medical and Consumer Market Research

Medical Professionals

If you are interested in participating in our surveys and focus groups, please complete the form below.

Our topics would include new medications and treatments that would benefit both you and your patients. The information you provide will help us to match your qualifications with our projects.

If you are chosen, you will receive an honorarium for your participation.

First Name:

Last Name:

Practice #

Fax #:

Cell #:

Pager #

Email:

Confirmation Email:

Practice Address:

Practice Suite:

Practice City:

Practice State:

Practice Zip:

Date of Birth:

PHYSICIANS ONLY: COMPLETE THE QUESTIONS BELOW
Primary Specialty:
Sub Specialty:
Topics of Specific Interest:
Years of Practice:
Hospital(s)/Clinic(s):
Are you in a private/solo practice?	Yes No
Are you in a group practice?	Yes No

RNs AND OTHER MEDICAL PERSONNEL ONLY: COMPLETE THE QUESTIONS BELOW
Primary Specialty:
Sub Specialty:

PHARMACISTS ONLY: COMPLETE THE QUESTIONS BELOW
Do you work in a retail pharmacy?	Yes No
Do you work in a hospital pharmacy?	Yes No

I agree to provide Field Research with this information for purposes of participation in market research events. This information will not be used for any other purposes and will be kept strictly confidential.

High Quality Medical and Consumer Market Research

Medical Professionals

PHYSICIANS ONLY: COMPLETE THE QUESTIONS BELOW

RNs AND OTHER MEDICAL PERSONNEL ONLY: COMPLETE THE QUESTIONS BELOW

PHARMACISTS ONLY: COMPLETE THE QUESTIONS BELOW