Personnel
Contact Information

Delta Marketing Dynamics
4207 Taylor Road
Jamesville, NY 13078
phone: (315)492-2905
fax: (315) 492-1740
deltamarketingdynamics.com

William R. Little
President
email: wrlittle@deltamktgdyn.com

Linda G. Crolick
Manager of Syndicated Studies
email: lcrolick@deltamktgdyn.com

Patty Trainor
Director of Primary Research
email: ptrainor@deltamktgdyn.com

Joan Brayman
Manager of Pricing
and Deals Reporting
email: jbrayman@deltamktgdyn.com

Webmaster
email: webmaster@deltamktgdyn.com

PHYSICIAN PANEL REGISTRATION FORM

Please provide as much information as possible.  As stated in our
Privacy Policy, DMD will never provide respondent-identifiable information
in any report, nor will we release your personal information to
outside parties unless you give us express permission to do so.

  Title    Suffix   
  First Name
  Last Name
  Practice or Hospital Name
  Address1
  Dept
  Address2
  Mail Drop #
  City
  State
  Zip Code
  Telephone #
  Fax #
  Primary Specialty
  If other, please specify:
  Sub-Specialty
  If other, please specify:
  Please complete if you wish to receive surveys at your home address: Address
City
State
Zip Code
  Please check how you would prefer to have honorariums paid: Pay honorariums to practice or hospital above
Pay honorariums directly to me
  Do you have access to the world wide web? Check if "Yes"
  May we contact you by email to present survey and honorarium opportunities? Check if "Yes"
  Please enter your email address:
  Is this your practice email address or your home email address? Practice email address
  Home email address
  Are you a registered pharmacist? Check if "Yes"
  What year did you begin as a physician?
  What year did you begin with the practice or hospital listed above?
  What type of practice are you involved in? Group   Single
  If a group practice, how many physicians are in the practice?
  How many patients do you treat annually?
  What are your patient demographics, in terms of age and the patient load you treat? Patient Load      Age

       0-2
       3-12
       13-18
       19-55
       56 +
Total -  100 %

  What is your managed care affiliation?
  In terms of payment for services, please estimate the following:

 Patients paying in cash
Patients using Medicare
Patients using 3rd party plans
(includes managed care)
  What type of setting is your practice located in?