Referring Provider Survey

<!DOCTYPE html> <html lang="en"> <head> <meta name="robots" content="noindex"> <meta http-equiv="Content-Type" content="text/html;charset=utf-8"> <meta name="viewport" content="width=device-width, initial-scale=1.0"> <meta http-equiv="X-UA-Compatible" content="IE=edge"> <title>Referring Provider Survey</title> <link id="ss__cs" rel="stylesheet" href="p705078301510/stylesheet/?executionMode=Cawi&unique=99-346&rm=1&responsive=true&pageMaster=Main+theme" type="text/css"> <link id="Source Sans Pro-google-fonts" rel="stylesheet" href="https://fonts.googleapis.com/css2?family=Source+Sans+Pro&display=swap" type="text/css"> <script type="text/javascript" src="https://hxplatform.pressganey.com/cf_clientutil/se/v2/responsive.js?v=346"></script> </head> <body class="cf-page " > <form action="/wix/p705078301510.aspx" method="post" novalidate="novalidate" class="cf-page__form" id="page_form" autocomplete="off" aria-hidden="true"> <div class="cf-page__hidden-fields"> <input type="hidden" 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text description" class="cf-header-logo__img"/></div> </div> </div> <div class="cf-page__main" role="form"> <div class="cf-page__question-list" aria-live="polite" aria-atomic="false" aria-relevant="additions removals"> <div class="cf-question cf-question--info" id="i1"> <div class="cf-question__text" id="i1_text"> <div class="OutlineElement Ltr SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; clear: both; cursor: text; overflow: visible; direction: ltr; color: #000000; font-family: 'Segoe UI', 'Segoe UI Web', Arial, Verdana, sans-serif; font-size: 12px; white-space: normal; background-color: #ffffff;"> <p class="Paragraph SCXW170189086 BCX8" style="margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;"><span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="TextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;">We value your partnership and appreciate your referrals.聽</span><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;"> </span></span></span></p> <p class="Paragraph SCXW170189086 BCX8" style="margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;" data-rte-root="true">聽</p> <p class="Paragraph SCXW170189086 BCX8" style="margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;" data-rte-root="true"><span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="TextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;">As part of our commitment to continually improve our referral process and better serve your needs, </span><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;">we <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;">would appreciate your feedback </span></span><span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="NormalTextRun ContextualSpellingAndGrammarErrorV2Themed SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlContextualSpellingAndGrammarErrorV2,); border-bottom: 1px solid transparent;">to</span><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;"> a few questions.</span></span></span><span class="EOP SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;" data-ccp-props="{"134233117":true,"134233118":true}">聽</span></span></p> <p class="Paragraph SCXW170189086 BCX8" style="margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;" data-rte-root="true">聽</p> </div> <div class="OutlineElement Ltr SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; clear: both; cursor: text; overflow: visible; direction: ltr; color: #000000; font-family: 'Segoe UI', 'Segoe UI Web', Arial, Verdana, sans-serif; font-size: 12px; white-space: normal; background-color: #ffffff;"> <p class="Paragraph SCXW170189086 BCX8" style="margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;"><span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="TextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;">The purpose of this survey is to assess our referral process and </span><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;">identify</span><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;"> areas where we can improve.聽</span></span><span class="EOP SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;" data-ccp-props="{"134233117":true,"134233118":true}">聽</span></span></p> </div> <div class="OutlineElement Ltr SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; clear: both; cursor: text; overflow: visible; direction: ltr; color: #000000; font-family: 'Segoe UI', 'Segoe UI Web', Arial, Verdana, sans-serif; font-size: 12px; white-space: normal; background-color: #ffffff;"> <p class="Paragraph SCXW170189086 BCX8" style="margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;"><span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="TextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;">The survey should take no more than 5 minutes to complete</span><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;">.聽</span><span class="NormalTextRun SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text;">聽</span></span><span class="EOP SCXW170189086 BCX8" style="margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;" data-ccp-props="{"134233117":true,"134233118":true}">聽</span></span></p> </div> </div> <div class="cf-question__instruction" id="i1_instruction"> </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="i1_error" role="alert" aria-labelledby="i1_error_list"> <ul class="cf-error-list" id="i1_error_list"> </ul> </div> </div> <div class="cf-question cf-question--single" id="q2"> <div class="cf-question__text" id="q2_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="TextRun SCXW72831359 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 12pt; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW72831359 BCX8" style="margin: 0px; padding: 0px; user-select: text;">Which title best describes your position?</span></span><span class="EOP SCXW72831359 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 12pt; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" data-ccp-props="{"134233117":true,"134233118":true}">聽</span></span> </div> <div class="cf-question__instruction" id="q2_instruction"> </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q2_error" role="alert" aria-labelledby="q2_error_list"> <ul class="cf-error-list" id="q2_error_list"> </ul> </div> <div class="cf-question__content" id="q2_content"> <div class="cf-list " role="radiogroup" aria-readonly="false" aria-labelledby="q2_title q2_text" aria-required="true" aria-invalid="false" aria-errormessage="q2_error"> <div class="cf-list__item" > <div class="cf-radio-answer " id="q2_1"> <div class="cf-radio-answer__control"> <div id="q2_1_control" class="cf-radio " role="radio" aria-checked="false" tabindex="0" aria-labelledby="q2_1_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q2_1_text"> Physician </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q2_2"> <div class="cf-radio-answer__control"> <div id="q2_2_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q2_2_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q2_2_text"> Nurse </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q2_3"> <div class="cf-radio-answer__control"> <div id="q2_3_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q2_3_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q2_3_text"> Physician Assistant </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q2_4"> <div class="cf-radio-answer__control"> <div id="q2_4_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q2_4_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q2_4_text"> Registered nurse </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q2_5"> <div class="cf-radio-answer__control"> <div id="q2_5_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q2_5_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q2_5_text"> Medical assistant </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q2_6"> <div class="cf-radio-answer__control"> <div id="q2_6_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q2_6_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q2_6_text"> Front desk staff </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q2_7"> <div class="cf-radio-answer__control"> <div id="q2_7_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q2_7_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q2_7_text"> Referral coordinator </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q2_8"> <div class="cf-radio-answer__control"> <div id="q2_8_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q2_8_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q2_8_text"> Case manager </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q2_9"> <div class="cf-radio-answer__control"> <div id="q2_9_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q2_9_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q2_9_text"> Social worker </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q2_10"> <div class="cf-radio-answer__control"> <div id="q2_10_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-label="Other"></div> </div> <div class="cf-radio-answer__content"> <input id="q2_10_other" class="cf-radio-answer__other cf-text-box" placeholder="Other" tabindex="-1" aria-hidden="true" aria-label="Other" autocomplete="off" type="text"/> </div> </div> </div> </div> </div> </div> <div class="cf-question cf-question--open" id="q3"> <div class="cf-question__text" id="q3_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="NormalTextRun SCXW6348639 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">What is your medical specialty</span><span class="NormalTextRun SCXW6348639 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">?</span></span> </div> <div class="cf-question__instruction" id="q3_instruction"> </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q3_error" role="alert" aria-labelledby="q3_error_list"> <ul class="cf-error-list" id="q3_error_list"> </ul> </div> <div class="cf-question__content cf-question__content--no-padding" id="q3_content"> <div class="cf-open-answer"> <textarea class="cf-open-answer__input cf-text-area " id="q3_input" aria-labelledby="q3_title q3_text" aria-required="true" aria-invalid="false" aria-errormessage="q3_error"></textarea> </div> </div> </div> <div class="cf-question cf-question--multi" id="q4"> <div class="cf-question__text" id="q4_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="NormalTextRun SCXW239014615 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">To which</span><span class="NormalTextRun SCXW239014615 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;"> area</span><span class="NormalTextRun SCXW239014615 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">s</span><span class="NormalTextRun SCXW239014615 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;"> do you </span><span class="NormalTextRun SCXW239014615 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">typically</span><span class="NormalTextRun SCXW239014615 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;"> refer a patient to?</span><span class="NormalTextRun SCXW239014615 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;"> </span></span> </div> <div class="cf-question__instruction" id="q4_instruction"> Select all that apply </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q4_error" role="alert" aria-labelledby="q4_error_list"> <ul class="cf-error-list" id="q4_error_list"> </ul> </div> <div class="cf-question__content" id="q4_content"> <div class="cf-list " role="group" aria-labelledby="q4_title q4_text q4_instruction" aria-invalid="false" aria-errormessage="q4_error"> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q4_1"> <div class="cf-checkbox-answer__control"> <div id="q4_1_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q4_1_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q4_1_text"> Lab </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q4_2"> <div class="cf-checkbox-answer__control"> <div id="q4_2_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q4_2_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q4_2_text"> Imaging </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q4_3"> <div class="cf-checkbox-answer__control"> <div id="q4_3_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q4_3_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q4_3_text"> Medical Specialty </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q4_4"> <div class="cf-checkbox-answer__control"> <div id="q4_4_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q4_4_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q4_4_text"> Surgery </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q4_5"> <div class="cf-checkbox-answer__control"> <div id="q4_5_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-label="Other"></div> </div> <div class="cf-checkbox-answer__content"> <input id="q4_5_other" class="cf-checkbox-answer__other cf-text-box" placeholder="Other" tabindex="-1" aria-hidden="true" aria-label="Other" autocomplete="off" type="text"/> </div> </div> </div> </div> </div> </div> <div class="cf-question cf-question--multi" id="q5"> <div class="cf-question__text" id="q5_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="NormalTextRun SCXW99927464 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">Which referral pathways do you currently use</span><span class="NormalTextRun SCXW99927464 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">?</span></span> </div> <div class="cf-question__instruction" id="q5_instruction"> Select all that apply </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q5_error" role="alert" aria-labelledby="q5_error_list"> <ul class="cf-error-list" id="q5_error_list"> </ul> </div> <div class="cf-question__content" id="q5_content"> <div class="cf-list " role="group" aria-labelledby="q5_title q5_text q5_instruction" aria-invalid="false" aria-errormessage="q5_error"> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q5_1"> <div class="cf-checkbox-answer__control"> <div id="q5_1_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q5_1_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q5_1_text"> Fax </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q5_2"> <div class="cf-checkbox-answer__control"> <div id="q5_2_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q5_2_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q5_2_text"> Email </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q5_3"> <div class="cf-checkbox-answer__control"> <div id="q5_3_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q5_3_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q5_3_text"> Phone </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q5_4"> <div class="cf-checkbox-answer__control"> <div id="q5_4_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q5_4_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q5_4_text"> Health Connect </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q5_5"> <div class="cf-checkbox-answer__control"> <div id="q5_5_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q5_5_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q5_5_text"> Online Referral Form </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q5_6"> <div class="cf-checkbox-answer__control"> <div id="q5_6_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q5_6_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q5_6_text"> EMR to EMR </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q5_7"> <div class="cf-checkbox-answer__control"> <div id="q5_7_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-label="Other"></div> </div> <div class="cf-checkbox-answer__content"> <input id="q5_7_other" class="cf-checkbox-answer__other cf-text-box" placeholder="Other" tabindex="-1" aria-hidden="true" aria-label="Other" autocomplete="off" type="text"/> </div> </div> </div> </div> </div> </div> <div class="cf-question cf-question--ranking" id="q6"> <div class="cf-question__text" id="q6_text"> <span class="TextRun SCXW146580512 BCX8" style="accent-color: auto; place-content: normal; place-items: normal; place-self: auto; alignment-baseline: auto; anchor-name: none; animation: 0s ease 0s 1 normal none running none; animation-composition: replace; app-region: none; appearance: none; aspect-ratio: auto; backdrop-filter: none; backface-visibility: visible; background: none 0% 0% / auto repeat scroll padding-box border-box rgba(0, 0, 0, 0); background-blend-mode: normal; baseline-shift: 0px; baseline-source: auto; border-collapse: separate; border-end-end-radius: 0px; border-end-start-radius: 0px; border-start-end-radius: 0px; border-start-start-radius: 0px; border-radius: 0px; inset: auto; box-shadow: none; box-sizing: content-box; break-after: auto; break-before: auto; break-inside: auto; buffered-rendering: auto; caption-side: top; caret-color: #000000; clear: none; clip: auto; clip-path: none; clip-rule: nonzero; color: #000000; color-interpolation: srgb; color-interpolation-filters: linearrgb; color-rendering: auto; color-scheme: normal; columns: auto; column-fill: balance; gap: normal; column-rule-width: 0px; column-rule-color: #000000; column-span: none; contain: none; contain-intrinsic-block-size: none; contain-intrinsic-size: none; contain-intrinsic-inline-size: none; container: none; content: normal; content-visibility: visible; counter-increment: none; counter-reset: none; counter-set: none; cursor: text; cx: 0px; cy: 0px; d: none; direction: ltr; display: inline; dominant-baseline: auto; empty-cells: show; field-sizing: fixed; fill: #000000; fill-opacity: 1; fill-rule: nonzero; filter: none; flex: 0 1 auto; flex-flow: row; float: none; flood-color: #000000; flood-opacity: 1; font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif; font-feature-settings: normal; font-kerning: none; font-optical-sizing: auto; font-palette: normal; font-size: 16px; font-size-adjust: none; font-stretch: 100%; font-synthesis: weight style small-caps; font-variation-settings: normal; forced-color-adjust: auto; grid-area: auto; grid: none; height: auto; hyphenate-character: auto; hyphenate-limit-chars: auto; hyphens: manual; image-orientation: from-image; image-rendering: auto; initial-letter: normal; inline-size: auto; inset-area: none; inset-block: auto; inset-inline: auto; isolation: auto; lighting-color: #ffffff; line-break: auto; line-height: 20.5042px; list-style: outside none disc; margin: 0px; marker: none; mask-image: none; mask-size: auto; mask-repeat: repeat; mask-origin: border-box; mask-clip: border-box; mask-composite: add; mask-mode: match-source; mask-type: luminance; math-depth: 0; math-shift: normal; math-style: normal; max-height: none; max-width: none; min-height: 0px; min-width: 0px; mix-blend-mode: normal; object-fit: fill; object-position: 50% 50%; object-view-box: none; offset: normal; opacity: 1; order: 0; outline: #000000 none 0px; outline-offset: 0px; overflow: visible; overflow-anchor: auto; overflow-clip-margin: 0px; overflow-wrap: break-word; overlay: none; overscroll-behavior-block: auto; overscroll-behavior-inline: auto; overscroll-behavior: auto; padding: 0px; page: auto; paint-order: normal; perspective: none; perspective-origin: 0px 0px; pointer-events: auto; position-anchor: auto; position-try: none; position-visibility: always; quotes: auto; r: 0px; resize: none; rotate: none; ruby-align: space-around; ruby-position: over; rx: auto; ry: auto; scale: none; scroll-behavior: auto; scroll-margin-block: 0px; scroll-margin: 0px; scroll-margin-inline: 0px; scroll-padding-block: auto; scroll-padding: auto; scroll-padding-inline: auto; scroll-snap-align: none; scroll-snap-stop: normal; scroll-snap-type: none; scroll-timeline: none; scrollbar-color: auto; scrollbar-gutter: auto; scrollbar-width: auto; shape-image-threshold: 0; shape-margin: 0px; shape-outside: none; shape-rendering: auto; speak: normal; stop-color: #000000; stop-opacity: 1; stroke: none; stroke-dasharray: none; stroke-dashoffset: 0px; stroke-linecap: butt; stroke-linejoin: miter; stroke-miterlimit: 4; stroke-opacity: 1; stroke-width: 1px; tab-size: 8; table-layout: auto; text-align: left; text-align-last: auto; text-anchor: start; text-combine-upright: none; text-decoration-line: none; text-decoration-style: solid; text-decoration-color: #000000; text-decoration-skip-ink: auto; text-emphasis: none #000000; text-emphasis-position: over; text-orientation: mixed; text-overflow: clip; text-rendering: auto; text-shadow: none; text-spacing-trim: normal; text-underline-offset: auto; text-underline-position: auto; white-space: pre-wrap; timeline-scope: none; touch-action: auto; transform: none; transform-box: view-box; transform-origin: 0px 0px; transform-style: flat; transition: all; translate: none; unicode-bidi: normal; user-select: text; vector-effect: none; vertical-align: baseline; view-timeline: none; view-transition-class: none; view-transition-name: none; visibility: visible; border-block: 0px none #000000; border-inline: 0px none #000000; block-size: auto; margin-block: 0px; margin-inline: 0px; max-block-size: none; max-inline-size: none; min-block-size: 0px; min-inline-size: 0px; padding-block: 0px; padding-inline: 0px; width: auto; will-change: auto; word-break: normal; writing-mode: horizontal-tb; x: 0px; y: 0px; z-index: auto; zoom: 1; border: 0px none #000000;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW146580512 BCX8">Please select your top three preferred referral pathways</span></span> </div> <div class="cf-question__instruction" id="q6_instruction"> <span class="TextRun SCXW205551965 BCX8" style="accent-color: auto; place-content: normal; place-items: normal; place-self: auto; alignment-baseline: auto; anchor-name: none; animation: 0s ease 0s 1 normal none running none; animation-composition: replace; app-region: none; appearance: none; aspect-ratio: auto; backdrop-filter: none; backface-visibility: visible; background: none 0% 0% / auto repeat scroll padding-box border-box rgba(0, 0, 0, 0); background-blend-mode: normal; baseline-shift: 0px; baseline-source: auto; border-collapse: separate; border-end-end-radius: 0px; border-end-start-radius: 0px; border-start-end-radius: 0px; border-start-start-radius: 0px; border-radius: 0px; inset: auto; box-shadow: none; box-sizing: content-box; break-after: auto; break-before: auto; break-inside: auto; buffered-rendering: auto; caption-side: top; caret-color: #000000; clear: none; clip: auto; clip-path: none; clip-rule: nonzero; color: #000000; color-interpolation: srgb; color-interpolation-filters: linearrgb; color-rendering: auto; color-scheme: normal; columns: auto; column-fill: balance; gap: normal; column-rule-width: 0px; column-rule-color: #000000; column-span: none; contain: none; contain-intrinsic-block-size: none; contain-intrinsic-size: none; contain-intrinsic-inline-size: none; container: none; content: normal; content-visibility: visible; counter-increment: none; counter-reset: none; counter-set: none; cursor: text; cx: 0px; cy: 0px; d: none; direction: ltr; display: inline; dominant-baseline: auto; empty-cells: show; field-sizing: fixed; fill: #000000; fill-opacity: 1; fill-rule: nonzero; filter: none; flex: 0 1 auto; flex-flow: row; float: none; flood-color: #000000; flood-opacity: 1; font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif; font-feature-settings: normal; font-kerning: none; font-optical-sizing: auto; font-palette: normal; font-size: 16px; font-size-adjust: none; font-stretch: 100%; font-synthesis: weight style small-caps; font-variation-settings: normal; forced-color-adjust: auto; grid-area: auto; grid: none; height: auto; hyphenate-character: auto; hyphenate-limit-chars: auto; hyphens: manual; image-orientation: from-image; image-rendering: auto; initial-letter: normal; inline-size: auto; inset-area: none; inset-block: auto; inset-inline: auto; isolation: auto; lighting-color: #ffffff; line-break: auto; line-height: 20.5042px; list-style: outside none disc; margin: 0px; marker: none; mask-image: none; mask-size: auto; mask-repeat: repeat; mask-origin: border-box; mask-clip: border-box; mask-composite: add; mask-mode: match-source; mask-type: luminance; math-depth: 0; math-shift: normal; math-style: normal; max-height: none; max-width: none; min-height: 0px; min-width: 0px; mix-blend-mode: normal; object-fit: fill; object-position: 50% 50%; object-view-box: none; offset: normal; opacity: 1; order: 0; outline: #000000 none 0px; outline-offset: 0px; overflow: visible; overflow-anchor: auto; overflow-clip-margin: 0px; overflow-wrap: break-word; overlay: none; overscroll-behavior-block: auto; overscroll-behavior-inline: auto; overscroll-behavior: auto; padding: 0px; page: auto; paint-order: normal; perspective: none; perspective-origin: 0px 0px; pointer-events: auto; position-anchor: auto; position-try: none; position-visibility: always; quotes: auto; r: 0px; resize: none; rotate: none; ruby-align: space-around; ruby-position: over; rx: auto; ry: auto; scale: none; scroll-behavior: auto; scroll-margin-block: 0px; scroll-margin: 0px; scroll-margin-inline: 0px; scroll-padding-block: auto; scroll-padding: auto; scroll-padding-inline: auto; scroll-snap-align: none; scroll-snap-stop: normal; scroll-snap-type: none; scroll-timeline: none; scrollbar-color: auto; scrollbar-gutter: auto; scrollbar-width: auto; shape-image-threshold: 0; shape-margin: 0px; shape-outside: none; shape-rendering: auto; speak: normal; stop-color: #000000; stop-opacity: 1; stroke: none; stroke-dasharray: none; stroke-dashoffset: 0px; stroke-linecap: butt; stroke-linejoin: miter; stroke-miterlimit: 4; stroke-opacity: 1; stroke-width: 1px; tab-size: 8; table-layout: auto; text-align: left; text-align-last: auto; text-anchor: start; text-combine-upright: none; text-decoration-line: none; text-decoration-style: solid; text-decoration-color: #000000; text-decoration-skip-ink: auto; text-emphasis: none #000000; text-emphasis-position: over; text-orientation: mixed; text-overflow: clip; text-rendering: auto; text-shadow: none; text-spacing-trim: normal; text-underline-offset: auto; text-underline-position: auto; white-space: pre-wrap; timeline-scope: none; touch-action: auto; transform: none; transform-box: view-box; transform-origin: 0px 0px; transform-style: flat; transition: all; translate: none; unicode-bidi: normal; user-select: text; vector-effect: none; vertical-align: baseline; view-timeline: none; view-transition-class: none; view-transition-name: none; visibility: visible; border-block: 0px none #000000; border-inline: 0px none #000000; block-size: auto; margin-block: 0px; margin-inline: 0px; max-block-size: none; max-inline-size: none; min-block-size: 0px; min-inline-size: 0px; padding-block: 0px; padding-inline: 0px; width: auto; will-change: auto; word-break: normal; writing-mode: horizontal-tb; x: 0px; y: 0px; z-index: auto; zoom: 1; border: 0px none #000000;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW205551965 BCX8">(1 is most preferred)</span></span> </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q6_error" role="alert" aria-labelledby="q6_error_list"> <ul class="cf-error-list" id="q6_error_list"> </ul> </div> <div class="cf-question__content" id="q6_content"> <div class="cf-list cf-list--narrow " > <div class="cf-list__item cf-ranking-answer " id="q6_1" tabindex="0" role="button" aria-pressed="false" aria-labelledby="q6_1_text"> <div class="cf-ranking-answer__rank">-</div> <div class="cf-ranking-answer__content"> <div class="cf-ranking-answer__text" id="q6_1_text">Fax</div> </div> </div> <div class="cf-list__item cf-ranking-answer " id="q6_2" tabindex="0" role="button" aria-pressed="false" aria-labelledby="q6_2_text"> <div class="cf-ranking-answer__rank">-</div> <div class="cf-ranking-answer__content"> <div class="cf-ranking-answer__text" id="q6_2_text">Email</div> </div> </div> <div class="cf-list__item cf-ranking-answer " id="q6_3" tabindex="0" role="button" aria-pressed="false" aria-labelledby="q6_3_text"> <div class="cf-ranking-answer__rank">-</div> <div class="cf-ranking-answer__content"> <div class="cf-ranking-answer__text" id="q6_3_text">Phone</div> </div> </div> <div class="cf-list__item cf-ranking-answer " id="q6_4" tabindex="0" role="button" aria-pressed="false" aria-labelledby="q6_4_text"> <div class="cf-ranking-answer__rank">-</div> <div class="cf-ranking-answer__content"> <div class="cf-ranking-answer__text" id="q6_4_text">Health Connect</div> </div> </div> <div class="cf-list__item cf-ranking-answer " id="q6_5" tabindex="0" role="button" aria-pressed="false" aria-labelledby="q6_5_text"> <div class="cf-ranking-answer__rank">-</div> <div class="cf-ranking-answer__content"> <div class="cf-ranking-answer__text" id="q6_5_text">Online Referral Form</div> </div> </div> <div class="cf-list__item cf-ranking-answer " id="q6_6" tabindex="0" role="button" aria-pressed="false" aria-labelledby="q6_6_text"> <div class="cf-ranking-answer__rank">-</div> <div class="cf-ranking-answer__content"> <div class="cf-ranking-answer__text" id="q6_6_text">EMR to EMR</div> </div> </div> <div class="cf-list__item cf-ranking-answer " id="q6_7" tabindex="0" role="button" aria-pressed="false" aria-label="Other"> <div class="cf-ranking-answer__rank">-</div> <div class="cf-ranking-answer__content"> <input class="cf-text-box cf-text-box--text-aligned cf-ranking-answer__other-input " type="text" id="q6_7_other" value="" placeholder="Other" autocomplete="off" tabindex="-1" aria-label="Other" aria-hidden="true"/> </div> </div> </div> <div class="cf-ranking-status " aria-live="polite"><span class="TextRun SCXW146580512 BCX8" style="accent-color: auto; place-content: normal; place-items: normal; place-self: auto; alignment-baseline: auto; anchor-name: none; animation: 0s ease 0s 1 normal none running none; animation-composition: replace; app-region: none; appearance: none; aspect-ratio: auto; backdrop-filter: none; backface-visibility: visible; background: none 0% 0% / auto repeat scroll padding-box border-box rgba(0, 0, 0, 0); background-blend-mode: normal; baseline-shift: 0px; baseline-source: auto; border-collapse: separate; border-end-end-radius: 0px; border-end-start-radius: 0px; border-start-end-radius: 0px; border-start-start-radius: 0px; border-radius: 0px; inset: auto; box-shadow: none; box-sizing: content-box; break-after: auto; break-before: auto; break-inside: auto; buffered-rendering: auto; caption-side: top; caret-color: #000000; clear: none; clip: auto; clip-path: none; clip-rule: nonzero; color: #000000; color-interpolation: srgb; color-interpolation-filters: linearrgb; color-rendering: auto; color-scheme: normal; columns: auto; column-fill: balance; gap: normal; column-rule-width: 0px; column-rule-color: #000000; column-span: none; contain: none; contain-intrinsic-block-size: none; contain-intrinsic-size: none; contain-intrinsic-inline-size: none; container: none; content: normal; content-visibility: visible; counter-increment: none; counter-reset: none; counter-set: none; cursor: text; cx: 0px; cy: 0px; d: none; direction: ltr; display: inline; dominant-baseline: auto; empty-cells: show; field-sizing: fixed; fill: #000000; fill-opacity: 1; fill-rule: nonzero; filter: none; flex: 0 1 auto; flex-flow: row; float: none; flood-color: #000000; flood-opacity: 1; font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif; font-feature-settings: normal; font-kerning: none; font-optical-sizing: auto; font-palette: normal; font-size: 16px; font-size-adjust: none; font-stretch: 100%; font-synthesis: weight style small-caps; font-variation-settings: normal; forced-color-adjust: auto; grid-area: auto; grid: none; height: auto; hyphenate-character: auto; hyphenate-limit-chars: auto; hyphens: manual; image-orientation: from-image; image-rendering: auto; initial-letter: normal; inline-size: auto; inset-area: none; inset-block: auto; inset-inline: auto; isolation: auto; lighting-color: #ffffff; line-break: auto; line-height: 20.5042px; list-style: outside none disc; margin: 0px; marker: none; mask-image: none; mask-size: auto; mask-repeat: repeat; mask-origin: border-box; mask-clip: border-box; mask-composite: add; mask-mode: match-source; mask-type: luminance; math-depth: 0; math-shift: normal; math-style: normal; max-height: none; max-width: none; min-height: 0px; min-width: 0px; mix-blend-mode: normal; object-fit: fill; object-position: 50% 50%; object-view-box: none; offset: normal; opacity: 1; order: 0; outline: #000000 none 0px; outline-offset: 0px; overflow: visible; overflow-anchor: auto; overflow-clip-margin: 0px; overflow-wrap: break-word; overlay: none; overscroll-behavior-block: auto; overscroll-behavior-inline: auto; overscroll-behavior: auto; padding: 0px; page: auto; paint-order: normal; perspective: none; perspective-origin: 0px 0px; pointer-events: auto; position-anchor: auto; position-try: none; position-visibility: always; quotes: auto; r: 0px; resize: none; rotate: none; ruby-align: space-around; ruby-position: over; rx: auto; ry: auto; scale: none; scroll-behavior: auto; scroll-margin-block: 0px; scroll-margin: 0px; scroll-margin-inline: 0px; scroll-padding-block: auto; scroll-padding: auto; scroll-padding-inline: auto; scroll-snap-align: none; scroll-snap-stop: normal; scroll-snap-type: none; scroll-timeline: none; scrollbar-color: auto; scrollbar-gutter: auto; scrollbar-width: auto; shape-image-threshold: 0; shape-margin: 0px; shape-outside: none; shape-rendering: auto; speak: normal; stop-color: #000000; stop-opacity: 1; stroke: none; stroke-dasharray: none; stroke-dashoffset: 0px; stroke-linecap: butt; stroke-linejoin: miter; stroke-miterlimit: 4; stroke-opacity: 1; stroke-width: 1px; tab-size: 8; table-layout: auto; text-align: left; text-align-last: auto; text-anchor: start; text-combine-upright: none; text-decoration-line: none; text-decoration-style: solid; text-decoration-color: #000000; text-decoration-skip-ink: auto; text-emphasis: none #000000; text-emphasis-position: over; text-orientation: mixed; text-overflow: clip; text-rendering: auto; text-shadow: none; text-spacing-trim: normal; text-underline-offset: auto; text-underline-position: auto; white-space: pre-wrap; timeline-scope: none; touch-action: auto; transform: none; transform-box: view-box; transform-origin: 0px 0px; transform-style: flat; transition: all; translate: none; unicode-bidi: normal; user-select: text; vector-effect: none; vertical-align: baseline; view-timeline: none; view-transition-class: none; view-transition-name: none; visibility: visible; border-block: 0px none #000000; border-inline: 0px none #000000; block-size: auto; margin-block: 0px; margin-inline: 0px; max-block-size: none; max-inline-size: none; min-block-size: 0px; min-inline-size: 0px; padding-block: 0px; padding-inline: 0px; width: auto; will-change: auto; word-break: normal; writing-mode: horizontal-tb; x: 0px; y: 0px; z-index: auto; zoom: 1; border: 0px none #000000;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW146580512 BCX8">Please select your top three preferred referral pathways</span></span>: </div> </div> </div> <div class="cf-question cf-question--single" id="q7"> <div class="cf-question__text" id="q7_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="TextRun SCXW545508 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 12pt; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW545508 BCX8" style="margin: 0px; padding: 0px; user-select: text;">How often do you refer patients to Vanderbilt Health?</span></span><span class="EOP SCXW545508 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 12pt; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" data-ccp-props="{"134233117":true,"134233118":true}">聽</span></span> </div> <div class="cf-question__instruction" id="q7_instruction"> </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q7_error" role="alert" aria-labelledby="q7_error_list"> <ul class="cf-error-list" id="q7_error_list"> </ul> </div> <div class="cf-question__content" id="q7_content"> <div class="cf-list " role="radiogroup" aria-readonly="false" aria-labelledby="q7_title q7_text" aria-required="true" aria-invalid="false" aria-errormessage="q7_error"> <div class="cf-list__item" > <div class="cf-radio-answer " id="q7_1"> <div class="cf-radio-answer__control"> <div id="q7_1_control" class="cf-radio " role="radio" aria-checked="false" tabindex="0" aria-labelledby="q7_1_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q7_1_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif; font-size: 16px; color: #7e8c8d;"><span class="TextRun SCXW193887307 BCX8" style="margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW193887307 BCX8" style="margin: 0px; padding: 0px; user-select: text;">Always (daily or multiple times a week)</span></span></span> </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q7_2"> <div class="cf-radio-answer__control"> <div id="q7_2_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q7_2_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q7_2_text"> <span class="TextRun SCXW241932753 BCX8" style="accent-color: auto; place-content: normal; place-items: normal; place-self: auto; alignment-baseline: auto; anchor-name: none; animation: 0s ease 0s 1 normal none running none; animation-composition: replace; app-region: none; appearance: none; aspect-ratio: auto; backdrop-filter: none; backface-visibility: visible; background: none 0% 0% / auto repeat scroll padding-box border-box rgba(0, 0, 0, 0); background-blend-mode: normal; baseline-shift: 0px; baseline-source: auto; border-collapse: separate; border-end-end-radius: 0px; border-end-start-radius: 0px; border-start-end-radius: 0px; border-start-start-radius: 0px; border-radius: 0px; inset: auto; box-shadow: none; box-sizing: content-box; break-after: auto; break-before: auto; break-inside: auto; buffered-rendering: auto; caption-side: top; caret-color: #000000; clear: none; clip: auto; clip-path: none; clip-rule: nonzero; color: #7e8c8d; color-interpolation: srgb; color-interpolation-filters: linearrgb; color-rendering: auto; color-scheme: normal; columns: auto; column-fill: balance; gap: normal; column-rule-width: 0px; column-rule-color: #000000; column-span: none; contain: none; contain-intrinsic-block-size: none; contain-intrinsic-size: none; contain-intrinsic-inline-size: none; container: none; content: normal; content-visibility: visible; counter-increment: none; counter-reset: none; counter-set: none; cursor: text; cx: 0px; cy: 0px; d: none; direction: ltr; display: inline; dominant-baseline: auto; empty-cells: show; field-sizing: fixed; fill: #000000; fill-opacity: 1; fill-rule: nonzero; filter: none; flex: 0 1 auto; flex-flow: row; float: none; flood-color: #000000; flood-opacity: 1; font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif; font-feature-settings: normal; font-kerning: none; font-optical-sizing: auto; font-palette: normal; font-size: 16px; font-size-adjust: none; font-stretch: 100%; font-synthesis: weight style small-caps; font-variation-settings: normal; forced-color-adjust: auto; grid-area: auto; grid: none; height: auto; hyphenate-character: auto; hyphenate-limit-chars: auto; hyphens: manual; image-orientation: from-image; image-rendering: auto; initial-letter: normal; inline-size: auto; inset-area: none; inset-block: auto; inset-inline: auto; isolation: auto; lighting-color: #ffffff; line-break: auto; line-height: 20.5042px; list-style: outside none disc; margin: 0px; marker: none; mask-image: none; mask-size: auto; mask-repeat: repeat; mask-origin: border-box; mask-clip: border-box; mask-composite: add; mask-mode: match-source; mask-type: luminance; math-depth: 0; math-shift: normal; math-style: normal; max-height: none; max-width: none; min-height: 0px; min-width: 0px; mix-blend-mode: normal; object-fit: fill; object-position: 50% 50%; object-view-box: none; offset: normal; opacity: 1; order: 0; outline: #000000 none 0px; outline-offset: 0px; overflow: visible; overflow-anchor: auto; overflow-clip-margin: 0px; overflow-wrap: break-word; overlay: none; overscroll-behavior-block: auto; overscroll-behavior-inline: auto; overscroll-behavior: auto; padding: 0px; page: auto; paint-order: normal; perspective: none; perspective-origin: 0px 0px; pointer-events: auto; position-anchor: auto; position-try: none; position-visibility: always; quotes: auto; r: 0px; resize: none; rotate: none; ruby-align: space-around; ruby-position: over; rx: auto; ry: auto; scale: none; scroll-behavior: auto; scroll-margin-block: 0px; scroll-margin: 0px; scroll-margin-inline: 0px; scroll-padding-block: auto; scroll-padding: auto; scroll-padding-inline: auto; scroll-snap-align: none; scroll-snap-stop: normal; scroll-snap-type: none; scroll-timeline: none; scrollbar-color: auto; scrollbar-gutter: auto; scrollbar-width: auto; shape-image-threshold: 0; shape-margin: 0px; shape-outside: none; shape-rendering: auto; speak: normal; stop-color: #000000; stop-opacity: 1; stroke: none; stroke-dasharray: none; stroke-dashoffset: 0px; stroke-linecap: butt; stroke-linejoin: miter; stroke-miterlimit: 4; stroke-opacity: 1; stroke-width: 1px; tab-size: 8; table-layout: auto; text-align: left; text-align-last: auto; text-anchor: start; text-combine-upright: none; text-decoration-skip-ink: auto; text-emphasis: none #000000; text-emphasis-position: over; text-orientation: mixed; text-overflow: clip; text-rendering: auto; text-shadow: none; text-spacing-trim: normal; text-underline-offset: auto; text-underline-position: auto; white-space: pre-wrap; timeline-scope: none; touch-action: auto; transform: none; transform-box: view-box; transform-origin: 0px 0px; transform-style: flat; transition: all; translate: none; unicode-bidi: normal; user-select: text; vector-effect: none; vertical-align: baseline; view-timeline: none; view-transition-class: none; view-transition-name: none; visibility: visible; border-block: 0px none #000000; border-inline: 0px none #000000; block-size: auto; margin-block: 0px; margin-inline: 0px; max-block-size: none; max-inline-size: none; min-block-size: 0px; min-inline-size: 0px; padding-block: 0px; padding-inline: 0px; width: auto; will-change: auto; word-break: normal; writing-mode: horizontal-tb; x: 0px; y: 0px; z-index: auto; zoom: 1; border: 0px none #000000;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW241932753 BCX8">Often (a few times a week)</span></span> </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q7_3"> <div class="cf-radio-answer__control"> <div id="q7_3_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q7_3_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q7_3_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif; font-size: 16px; color: #7e8c8d;"><span class="TextRun SCXW89347702 BCX8" style="margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW89347702 BCX8" style="margin: 0px; padding: 0px; user-select: text;">Sometimes (a few times a month)</span></span><span class="EOP SCXW89347702 BCX8" style="margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" data-ccp-props="{}">聽</span></span> </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q7_4"> <div class="cf-radio-answer__control"> <div id="q7_4_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q7_4_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q7_4_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif; font-size: 16px; color: #7e8c8d;"><span class="TextRun SCXW261208365 BCX8" style="margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW261208365 BCX8" style="margin: 0px; padding: 0px; user-select: text;">Rarely (1 a month or less)</span></span><span class="EOP SCXW261208365 BCX8" style="margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" data-ccp-props="{}">聽</span></span> </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q7_5"> <div class="cf-radio-answer__control"> <div id="q7_5_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q7_5_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q7_5_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif; font-size: 16px; color: #7e8c8d;"><span class="TextRun SCXW96932861 BCX8" style="margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW96932861 BCX8" style="margin: 0px; padding: 0px; user-select: text;">Never (no referrals in 6+ months)</span></span><span class="EOP SCXW96932861 BCX8" style="margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" data-ccp-props="{}">聽</span></span> </div> </div> </div> </div> </div> </div> </div> <div class="cf-question cf-question--single" id="q8"> <div class="cf-question__text" id="q8_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="TextRun SCXW50217806 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 12pt; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW50217806 BCX8" style="margin: 0px; padding: 0px; user-select: text;">H</span><span class="NormalTextRun SCXW50217806 BCX8" style="margin: 0px; padding: 0px; user-select: text;">ow would you rate your experience referring a patient to us?</span></span><span class="EOP SCXW50217806 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 12pt; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" data-ccp-props="{"134233117":true,"134233118":true}">聽</span></span> </div> <div class="cf-question__instruction" id="q8_instruction"> </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q8_error" role="alert" aria-labelledby="q8_error_list"> <ul class="cf-error-list" id="q8_error_list"> </ul> </div> <div class="cf-question__content" id="q8_content"> <div class="cf-list " role="radiogroup" aria-readonly="false" aria-labelledby="q8_title q8_text" aria-required="true" aria-invalid="false" aria-errormessage="q8_error"> <div class="cf-list__item" > <div class="cf-radio-answer " id="q8_1"> <div class="cf-radio-answer__control"> <div id="q8_1_control" class="cf-radio " role="radio" aria-checked="false" tabindex="0" aria-labelledby="q8_1_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q8_1_text"> Excellent </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q8_2"> <div class="cf-radio-answer__control"> <div id="q8_2_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q8_2_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q8_2_text"> Good </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q8_3"> <div class="cf-radio-answer__control"> <div id="q8_3_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q8_3_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q8_3_text"> Neutral </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q8_4"> <div class="cf-radio-answer__control"> <div id="q8_4_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q8_4_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q8_4_text"> Needs Improvement </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q8_5"> <div class="cf-radio-answer__control"> <div id="q8_5_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q8_5_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q8_5_text"> Very Poor </div> </div> </div> </div> </div> </div> </div> <div class="cf-question cf-question--single" id="q9"> <div class="cf-question__text" id="q9_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="TextRun SCXW227628729 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 12pt; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW227628729 BCX8" style="margin: 0px; padding: 0px; user-select: text;">How satisfied are you with the communication </span><span class="NormalTextRun SCXW227628729 BCX8" style="margin: 0px; padding: 0px; user-select: text;">regarding</span><span class="NormalTextRun SCXW227628729 BCX8" style="margin: 0px; padding: 0px; user-select: text;"> your referred patients?</span></span><span class="EOP SCXW227628729 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 12pt; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;" data-ccp-props="{"134233117":true,"134233118":true}">聽</span></span> </div> <div class="cf-question__instruction" id="q9_instruction"> </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q9_error" role="alert" aria-labelledby="q9_error_list"> <ul class="cf-error-list" id="q9_error_list"> </ul> </div> <div class="cf-question__content" id="q9_content"> <div class="cf-list " role="radiogroup" aria-readonly="false" aria-labelledby="q9_title q9_text" aria-required="true" aria-invalid="false" aria-errormessage="q9_error"> <div class="cf-list__item" > <div class="cf-radio-answer " id="q9_1"> <div class="cf-radio-answer__control"> <div id="q9_1_control" class="cf-radio " role="radio" aria-checked="false" tabindex="0" aria-labelledby="q9_1_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q9_1_text"> Very satisfied </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q9_2"> <div class="cf-radio-answer__control"> <div id="q9_2_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q9_2_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q9_2_text"> Somewhat satisfied </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q9_3"> <div class="cf-radio-answer__control"> <div id="q9_3_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q9_3_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q9_3_text"> Neutral </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q9_4"> <div class="cf-radio-answer__control"> <div id="q9_4_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q9_4_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q9_4_text"> Somewhat dissatisfied </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-radio-answer " id="q9_5"> <div class="cf-radio-answer__control"> <div id="q9_5_control" class="cf-radio " role="radio" aria-checked="false" tabindex="-1" aria-labelledby="q9_5_text"></div> </div> <div class="cf-radio-answer__content"> <div class="cf-radio-answer__text" id="q9_5_text"> Very dissatisfied </div> </div> </div> </div> </div> </div> </div> <div class="cf-question cf-question--multi" id="q10"> <div class="cf-question__text" id="q10_text"> <span class="TextRun SCXW177626900 BCX8" style="accent-color: auto; place-content: normal; place-items: normal; place-self: auto; alignment-baseline: auto; anchor-name: none; animation: 0s ease 0s 1 normal none running none; animation-composition: replace; app-region: none; appearance: none; aspect-ratio: auto; backdrop-filter: none; backface-visibility: visible; background: none 0% 0% / auto repeat scroll padding-box border-box rgba(0, 0, 0, 0); background-blend-mode: normal; baseline-shift: 0px; baseline-source: auto; border-collapse: separate; border-end-end-radius: 0px; border-end-start-radius: 0px; border-start-end-radius: 0px; border-start-start-radius: 0px; border-radius: 0px; inset: auto; box-shadow: none; box-sizing: content-box; break-after: auto; break-before: auto; break-inside: auto; buffered-rendering: auto; caption-side: top; caret-color: #000000; clear: none; clip: auto; clip-path: none; clip-rule: nonzero; color: #000000; color-interpolation: srgb; color-interpolation-filters: linearrgb; color-rendering: auto; color-scheme: normal; columns: auto; column-fill: balance; gap: normal; column-rule-width: 0px; column-rule-color: #000000; column-span: none; contain: none; contain-intrinsic-block-size: none; contain-intrinsic-size: none; contain-intrinsic-inline-size: none; container: none; content: normal; content-visibility: visible; counter-increment: none; counter-reset: none; counter-set: none; cursor: text; cx: 0px; cy: 0px; d: none; direction: ltr; display: inline; dominant-baseline: auto; empty-cells: show; field-sizing: fixed; fill: #000000; fill-opacity: 1; fill-rule: nonzero; filter: none; flex: 0 1 auto; flex-flow: row; float: none; flood-color: #000000; flood-opacity: 1; font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif; font-feature-settings: normal; font-kerning: none; font-optical-sizing: auto; font-palette: normal; font-size: 16px; font-size-adjust: none; font-stretch: 100%; font-synthesis: weight style small-caps; font-variation-settings: normal; forced-color-adjust: auto; grid-area: auto; grid: none; height: auto; hyphenate-character: auto; hyphenate-limit-chars: auto; hyphens: manual; image-orientation: from-image; image-rendering: auto; initial-letter: normal; inline-size: auto; inset-area: none; inset-block: auto; inset-inline: auto; isolation: auto; lighting-color: #ffffff; line-break: auto; line-height: 20.5042px; list-style: outside none disc; margin: 0px; marker: none; mask-image: none; mask-size: auto; mask-repeat: repeat; mask-origin: border-box; mask-clip: border-box; mask-composite: add; mask-mode: match-source; mask-type: luminance; math-depth: 0; math-shift: normal; math-style: normal; max-height: none; max-width: none; min-height: 0px; min-width: 0px; mix-blend-mode: normal; object-fit: fill; object-position: 50% 50%; object-view-box: none; offset: normal; opacity: 1; order: 0; outline: #000000 none 0px; outline-offset: 0px; overflow: visible; overflow-anchor: auto; overflow-clip-margin: 0px; overflow-wrap: break-word; overlay: none; overscroll-behavior-block: auto; overscroll-behavior-inline: auto; overscroll-behavior: auto; padding: 0px; page: auto; paint-order: normal; perspective: none; perspective-origin: 0px 0px; pointer-events: auto; position-anchor: auto; position-try: none; position-visibility: always; quotes: auto; r: 0px; resize: none; rotate: none; ruby-align: space-around; ruby-position: over; rx: auto; ry: auto; scale: none; scroll-behavior: auto; scroll-margin-block: 0px; scroll-margin: 0px; scroll-margin-inline: 0px; scroll-padding-block: auto; scroll-padding: auto; scroll-padding-inline: auto; scroll-snap-align: none; scroll-snap-stop: normal; scroll-snap-type: none; scroll-timeline: none; scrollbar-color: auto; scrollbar-gutter: auto; scrollbar-width: auto; shape-image-threshold: 0; shape-margin: 0px; shape-outside: none; shape-rendering: auto; speak: normal; stop-color: #000000; stop-opacity: 1; stroke: none; stroke-dasharray: none; stroke-dashoffset: 0px; stroke-linecap: butt; stroke-linejoin: miter; stroke-miterlimit: 4; stroke-opacity: 1; stroke-width: 1px; tab-size: 8; table-layout: auto; text-align: left; text-align-last: auto; text-anchor: start; text-combine-upright: none; text-decoration-line: none; text-decoration-style: solid; text-decoration-color: #000000; text-decoration-skip-ink: auto; text-emphasis: none #000000; text-emphasis-position: over; text-orientation: mixed; text-overflow: clip; text-rendering: auto; text-shadow: none; text-spacing-trim: normal; text-underline-offset: auto; text-underline-position: auto; white-space: pre-wrap; timeline-scope: none; touch-action: auto; transform: none; transform-box: view-box; transform-origin: 0px 0px; transform-style: flat; transition: all; translate: none; unicode-bidi: normal; user-select: text; vector-effect: none; vertical-align: baseline; view-timeline: none; view-transition-class: none; view-transition-name: none; visibility: visible; border-block: 0px none #000000; border-inline: 0px none #000000; block-size: auto; margin-block: 0px; margin-inline: 0px; max-block-size: none; max-inline-size: none; min-block-size: 0px; min-inline-size: 0px; padding-block: 0px; padding-inline: 0px; width: auto; will-change: auto; word-break: normal; writing-mode: horizontal-tb; x: 0px; y: 0px; z-index: auto; zoom: 1; border: 0px none #000000;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW177626900 BCX8">Are there specific areas where you believe we could improve the referral process?</span></span> </div> <div class="cf-question__instruction" id="q10_instruction"> Select all that apply </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q10_error" role="alert" aria-labelledby="q10_error_list"> <ul class="cf-error-list" id="q10_error_list"> </ul> </div> <div class="cf-question__content" id="q10_content"> <div class="cf-list " role="group" aria-labelledby="q10_title q10_text q10_instruction" aria-invalid="false" aria-errormessage="q10_error"> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q10_1"> <div class="cf-checkbox-answer__control"> <div id="q10_1_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q10_1_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q10_1_text"> Finding appropriate provider to refer patient to </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q10_2"> <div class="cf-checkbox-answer__control"> <div id="q10_2_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q10_2_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q10_2_text"> Scheduling of patient </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q10_3"> <div class="cf-checkbox-answer__control"> <div id="q10_3_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q10_3_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q10_3_text"> Verification that patient has been scheduled </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q10_4"> <div class="cf-checkbox-answer__control"> <div id="q10_4_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-labelledby="q10_4_text"></div> </div> <div class="cf-checkbox-answer__content"> <div class="cf-checkbox-answer__text" id="q10_4_text"> Provider-to-Provider communication regarding patient </div> </div> </div> </div> <div class="cf-list__item" > <div class="cf-checkbox-answer " id="q10_5"> <div class="cf-checkbox-answer__control"> <div id="q10_5_control" class="cf-checkbox " role="checkbox" aria-checked="false" tabindex="0" aria-readonly="false" aria-label="Other"></div> </div> <div class="cf-checkbox-answer__content"> <input id="q10_5_other" class="cf-checkbox-answer__other cf-text-box" placeholder="Other" tabindex="-1" aria-hidden="true" aria-label="Other" autocomplete="off" type="text"/> </div> </div> </div> </div> </div> </div> <div class="cf-question cf-question--open" id="q11"> <div class="cf-question__text" id="q11_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="NormalTextRun SCXW112356565 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">Is there anything else you would like to share about your referral experience?</span><span class="NormalTextRun SCXW112356565 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;"> </span></span> </div> <div class="cf-question__instruction" id="q11_instruction"> </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q11_error" role="alert" aria-labelledby="q11_error_list"> <ul class="cf-error-list" id="q11_error_list"> </ul> </div> <div class="cf-question__content cf-question__content--no-padding" id="q11_content"> <div class="cf-open-answer"> <textarea class="cf-open-answer__input cf-text-area " id="q11_input" aria-labelledby="q11_title q11_text" aria-required="false" aria-invalid="false" aria-errormessage="q11_error"></textarea> </div> </div> </div> <div class="cf-question cf-question--open-list" id="q12"> <div class="cf-question__text" id="q12_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8" style="margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">Would you </span><span class="NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8" style="margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">be interested in joining an online advisory council where you will have </span><span class="NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8" style="margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">an opportunity</span><span class="NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8" style="margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;"> to provide feedback and receive regular updates on improvements to our </span><span class="NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8" style="margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">processes, including how you refer your patients to us</span><span class="NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8" style="margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">? </span></span> </div> <div class="cf-question__instruction" id="q12_instruction"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="NormalTextRun SCXW197219248 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;">If yes, please provide</span><span class="NormalTextRun SCXW197219248 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;"> your</span><span class="NormalTextRun SCXW197219248 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;"> email address / NPI #</span></span> </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="q12_error" role="alert" aria-labelledby="q12_error_list"> <ul class="cf-error-list" id="q12_error_list"> </ul> </div> <div class="cf-question__content" id="q12_content"> <div class="cf-grid-layout " > <div class="cf-grid-layout__row cf-open-list-answer " id="q12_1" > <div class="cf-grid-layout__row-text"> <div class="cf-open-list-answer__text" id="q12_1_text">Email Address</div> </div> <div class="cf-grid-layout__row-control cf-open-list-answer__control"> <div class="cf-affix-input-decorator "> <div class="cf-affix-input-decorator__input-wrapper"> <input type="text" class="cf-open-list-answer__input cf-text-box " id="q12_1_input" value="" aria-required="false" aria-labelledby="q12_1_text" /> </div> </div> </div> </div> <div class="cf-grid-layout__row cf-open-list-answer " id="q12_2" > <div class="cf-grid-layout__row-text"> <div class="cf-open-list-answer__text" id="q12_2_text">NPI Number</div> </div> <div class="cf-grid-layout__row-control cf-open-list-answer__control"> <div class="cf-affix-input-decorator "> <div class="cf-affix-input-decorator__input-wrapper"> <input type="text" class="cf-open-list-answer__input cf-text-box " id="q12_2_input" value="" aria-required="false" aria-labelledby="q12_2_text" /> </div> </div> </div> </div> </div> </div> </div> <div class="cf-question cf-question--info" id="i13"> <div class="cf-question__text" id="i13_text"> <span style="font-family: 'Helvetica Neue', Helvetica, Arial, sans-serif;"><span class="TextRun SCXW90568000 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; text-align: left; white-space: pre-wrap; background-color: #ffffff; font-size: 12pt; line-height: 20.5042px;" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW90568000 BCX8" style="margin: 0px; padding: 0px; user-select: text;">Thank you again for your participation in this survey. We are committed to using your feedback to improve our referral process and strengthen our partnership with you. We appreciate your continued trust and look forward to our ongoing collaboration.</span></span><span class="EOP SCXW90568000 BCX8" style="margin: 0px; padding: 0px; user-select: text; color: #000000; text-align: left; white-space: pre-wrap; background-color: #ffffff; font-size: 12pt; line-height: 20.5042px;" data-ccp-props="{"134233117":true,"134233118":true,"335572079":12,"335572080":1,"335572081":4278190080,"469789806":"single"}">聽</span> </span> </div> <div class="cf-question__instruction" id="i13_instruction"> </div> <div class="cf-question__error cf-error-block cf-error-block--bottom cf-error-block--hidden" id="i13_error" role="alert" aria-labelledby="i13_error_list"> <ul class="cf-error-list" id="i13_error_list"> </ul> </div> </div> </div> <div class="cf-page__navigation cf-navigation " role="navigation"> <button type="button" class="cf-navigation__button cf-navigation-ok">OK</button> </div> <div class="cf-page__powered-by-confirmit cf-powered-by-confirmit" > <a class="cf-powered-by-confirmit__link" href="https://www.forsta.com" target="_blank" >Powered by Forsta</a> </div> </div> <div class="cf-toast cf-toast--error cf-toast--hidden" aria-hidden="true"> <div class="cf-toast__wrapper"> <div class="cf-toast__content"> <ul class="cf-error-list"> </ul> </div> <div class="cf-toast__close"></div> </div> </div> <script type="text/javascript"> (function() { window.Confirmit = new window.cfApi([{"questionId":"i1","title":"Introduction","text":"\u003cdiv class=\u0022OutlineElement Ltr SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; clear: both; cursor: text; overflow: visible; direction: ltr; color: #000000; font-family: \u0027Segoe UI\u0027, \u0027Segoe UI Web\u0027, Arial, Verdana, sans-serif; font-size: 12px; white-space: normal; background-color: #ffffff;\u0022\u003e\n\u003cp class=\u0022Paragraph SCXW170189086 BCX8\u0022 style=\u0022margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;\u0022\u003e\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003e\u003cspan class=\u0022TextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;\u0022 xml:lang=\u0022EN-US\u0022 data-contrast=\u0022auto\u0022\u003e\u003cspan class=\u0022NormalTextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text;\u0022\u003eWe value your partnership and appreciate your referrals.聽\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text;\u0022\u003e \u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\u0022Paragraph SCXW170189086 BCX8\u0022 style=\u0022margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;\u0022 data-rte-root=\u0022true\u0022\u003e聽\u003c/p\u003e\n\u003cp class=\u0022Paragraph SCXW170189086 BCX8\u0022 style=\u0022margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;\u0022 data-rte-root=\u0022true\u0022\u003e\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003e\u003cspan class=\u0022TextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;\u0022 xml:lang=\u0022EN-US\u0022 data-contrast=\u0022auto\u0022\u003e\u003cspan class=\u0022NormalTextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text;\u0022\u003eAs part of our commitment to continually improve our referral process and better serve your needs, \u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text;\u0022\u003ewe \u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003ewould appreciate your feedback \u003c/span\u003e\u003c/span\u003e\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003e\u003cspan class=\u0022NormalTextRun ContextualSpellingAndGrammarErrorV2Themed SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlContextualSpellingAndGrammarErrorV2,); border-bottom: 1px solid transparent;\u0022\u003eto\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text;\u0022\u003e a few questions.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\u0022EOP SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;\u0022 data-ccp-props=\u0022{\u0026quot;134233117\u0026quot;:true,\u0026quot;134233118\u0026quot;:true}\u0022\u003e聽\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\u0022Paragraph SCXW170189086 BCX8\u0022 style=\u0022margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;\u0022 data-rte-root=\u0022true\u0022\u003e聽\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\u0022OutlineElement Ltr SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; clear: both; cursor: text; overflow: visible; direction: ltr; color: #000000; font-family: \u0027Segoe UI\u0027, \u0027Segoe UI Web\u0027, Arial, Verdana, sans-serif; font-size: 12px; white-space: normal; background-color: #ffffff;\u0022\u003e\n\u003cp class=\u0022Paragraph SCXW170189086 BCX8\u0022 style=\u0022margin: auto 0px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space: pre-wrap; vertical-align: baseline; font-kerning: none; color: windowtext; text-align: left;\u0022\u003e\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003e\u003cspan class=\u0022TextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.5042px;\u0022 xml:lang=\u0022EN-US\u0022 data-contrast=\u0022auto\u0022\u003e\u003cspan class=\u0022NormalTextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text;\u0022\u003eThe purpose of this survey is to assess our referral process and \u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text;\u0022\u003eidentify\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW170189086 BCX8\u0022 style=\u0022margin: 0px; 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padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003eWhat is your medical specialty\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW6348639 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e?\u003c/span\u003e\u003c/span\u003e","instruction":"","errorMessages":[],"nodeType":"OpenText","customRendering":false,"triggeredQuestions":[],"isRtl":false,"isAccessible":false,"customQuestion":null,"isCatiReviewingMode":false},{"answerButtons":false,"layoutColumns":0,"layoutRows":0,"values":[],"otherValues":{},"otherRows":null,"otherColumns":null,"multiCount":{"equal":null,"min":null,"max":null},"defaultValue":"","refusedValue":"","answers":[{"code":"1","score":null,"text":"Lab","rightText":null,"fieldName":"q4_1","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"2","score":null,"text":"Imaging","rightText":null,"fieldName":"q4_2","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"3","score":null,"text":"Medical Specialty","rightText":null,"fieldName":"q4_3","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"4","score":null,"text":"Surgery","rightText":null,"fieldName":"q4_4","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"5","score":null,"text":"Other","rightText":null,"fieldName":"q4_5","otherFieldName":"q4_5_other","other":{"value":null,"fieldName":"q4_5_other"},"isOther":true,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""}],"answerGroups":[],"readOnly":false,"required":true,"category":"","validationRules":[{"type":"Required","message":"Please select an answer.","validateOnBackwardNavigation":false},{"type":"OtherRequired","message":"Please provide an answer.","validateOnBackwardNavigation":false},{"type":"RequiredIfOtherSpecified","message":"Please select an answer.","validateOnBackwardNavigation":false}],"questionId":"q4","title":"Patient area","text":"\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003e\u003cspan class=\u0022NormalTextRun SCXW239014615 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003eTo which\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW239014615 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e area\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW239014615 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003es\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW239014615 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e do you \u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW239014615 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003etypically\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW239014615 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e refer a patient to?\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW239014615 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e \u003c/span\u003e\u003c/span\u003e","instruction":"Select all that apply","errorMessages":[],"nodeType":"Multi","customRendering":false,"triggeredQuestions":[],"isRtl":false,"isAccessible":false,"customQuestion":null,"isCatiReviewingMode":false},{"answerButtons":false,"layoutColumns":0,"layoutRows":0,"values":[],"otherValues":{},"otherRows":null,"otherColumns":null,"multiCount":{"equal":null,"min":null,"max":null},"defaultValue":"","refusedValue":"","answers":[{"code":"1","score":null,"text":"Fax","rightText":null,"fieldName":"q5_1","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"2","score":null,"text":"Email","rightText":null,"fieldName":"q5_2","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"3","score":null,"text":"Phone","rightText":null,"fieldName":"q5_3","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"4","score":null,"text":"Health Connect","rightText":null,"fieldName":"q5_4","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"5","score":null,"text":"Online Referral Form","rightText":null,"fieldName":"q5_5","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"6","score":null,"text":"EMR to EMR","rightText":null,"fieldName":"q5_6","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"7","score":null,"text":"Other","rightText":null,"fieldName":"q5_7","otherFieldName":"q5_7_other","other":{"value":null,"fieldName":"q5_7_other"},"isOther":true,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""}],"answerGroups":[],"readOnly":false,"required":true,"category":"","validationRules":[{"type":"Required","message":"Please select an answer.","validateOnBackwardNavigation":false},{"type":"OtherRequired","message":"Please provide an answer.","validateOnBackwardNavigation":false},{"type":"RequiredIfOtherSpecified","message":"Please select an answer.","validateOnBackwardNavigation":false}],"questionId":"q5","title":"Referral Pathway","text":"\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003e\u003cspan class=\u0022NormalTextRun SCXW99927464 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003eWhich referral pathways do you currently use\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW99927464 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e?\u003c/span\u003e\u003c/span\u003e","instruction":"Select all that apply","errorMessages":[],"nodeType":"Multi","customRendering":false,"triggeredQuestions":[],"isRtl":false,"isAccessible":false,"customQuestion":null,"isCatiReviewingMode":false},{"multiCount":{"equal":null,"min":1,"max":3},"values":{},"otherValues":{},"otherRows":null,"otherColumns":null,"layoutColumns":0,"layoutRows":0,"captureOrder":false,"answerButtons":false,"rankByNumber":false,"rankByDrag":false,"answers":[{"code":"1","score":null,"text":"Fax","rightText":null,"fieldName":"q6_1","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"2","score":null,"text":"Email","rightText":null,"fieldName":"q6_2","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"3","score":null,"text":"Phone","rightText":null,"fieldName":"q6_3","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"4","score":null,"text":"Health Connect","rightText":null,"fieldName":"q6_4","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"5","score":null,"text":"Online Referral Form","rightText":null,"fieldName":"q6_5","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"6","score":null,"text":"EMR to EMR","rightText":null,"fieldName":"q6_6","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"7","score":null,"text":"Other","rightText":null,"fieldName":"q6_7","otherFieldName":"q6_7_other","other":{"value":null,"fieldName":"q6_7_other"},"isOther":true,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""}],"answerGroups":[],"readOnly":false,"required":true,"category":"","validationRules":[{"type":"Required","message":"Please select an answer.","validateOnBackwardNavigation":false},{"type":"OtherRequired","message":"Please provide an answer.","validateOnBackwardNavigation":false},{"type":"RequiredIfOtherSpecified","message":"Please select an answer.","validateOnBackwardNavigation":false},{"type":"MultiCount","message":"Please select between 1 and 3 answers.","validateOnBackwardNavigation":false},{"type":"Ranking","message":"Please enter consecutive answers in the range 1 to 3.","validateOnBackwardNavigation":true}],"questionId":"q6","title":"Preferred Pathway","text":"\u003cspan class=\u0022TextRun SCXW146580512 BCX8\u0022 style=\u0022accent-color: auto; place-content: normal; place-items: normal; place-self: auto; alignment-baseline: auto; anchor-name: none; animation: 0s ease 0s 1 normal none running none; animation-composition: replace; app-region: none; appearance: none; aspect-ratio: auto; backdrop-filter: none; backface-visibility: visible; background: none 0% 0% / auto repeat scroll padding-box border-box rgba(0, 0, 0, 0); background-blend-mode: normal; baseline-shift: 0px; baseline-source: auto; border-collapse: separate; border-end-end-radius: 0px; border-end-start-radius: 0px; border-start-end-radius: 0px; border-start-start-radius: 0px; border-radius: 0px; inset: auto; box-shadow: none; box-sizing: content-box; break-after: auto; break-before: auto; break-inside: auto; buffered-rendering: auto; caption-side: top; caret-color: #000000; clear: none; clip: auto; clip-path: none; clip-rule: nonzero; color: #000000; color-interpolation: srgb; color-interpolation-filters: linearrgb; color-rendering: auto; color-scheme: normal; columns: auto; column-fill: balance; gap: normal; column-rule-width: 0px; column-rule-color: #000000; column-span: none; contain: none; contain-intrinsic-block-size: none; contain-intrinsic-size: none; contain-intrinsic-inline-size: none; container: none; content: normal; content-visibility: visible; counter-increment: none; counter-reset: none; counter-set: none; cursor: text; cx: 0px; cy: 0px; d: none; direction: ltr; display: inline; dominant-baseline: auto; empty-cells: show; field-sizing: fixed; fill: #000000; fill-opacity: 1; fill-rule: nonzero; filter: none; flex: 0 1 auto; flex-flow: row; float: none; flood-color: #000000; flood-opacity: 1; font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif; font-feature-settings: normal; font-kerning: none; font-optical-sizing: auto; font-palette: normal; font-size: 16px; font-size-adjust: none; font-stretch: 100%; font-synthesis: weight style small-caps; font-variation-settings: normal; forced-color-adjust: auto; grid-area: auto; grid: none; height: auto; hyphenate-character: auto; hyphenate-limit-chars: auto; hyphens: manual; image-orientation: from-image; image-rendering: auto; initial-letter: normal; inline-size: auto; inset-area: none; inset-block: auto; inset-inline: auto; isolation: auto; lighting-color: #ffffff; line-break: auto; line-height: 20.5042px; list-style: outside none disc; margin: 0px; marker: none; mask-image: none; mask-size: auto; mask-repeat: repeat; mask-origin: border-box; mask-clip: border-box; mask-composite: add; mask-mode: match-source; mask-type: luminance; math-depth: 0; math-shift: normal; math-style: normal; max-height: none; max-width: none; min-height: 0px; min-width: 0px; mix-blend-mode: normal; object-fit: fill; object-position: 50% 50%; object-view-box: none; offset: normal; opacity: 1; order: 0; outline: #000000 none 0px; outline-offset: 0px; overflow: visible; overflow-anchor: auto; overflow-clip-margin: 0px; overflow-wrap: break-word; overlay: none; overscroll-behavior-block: auto; overscroll-behavior-inline: auto; overscroll-behavior: auto; padding: 0px; page: auto; paint-order: normal; perspective: none; perspective-origin: 0px 0px; pointer-events: auto; position-anchor: auto; position-try: none; position-visibility: always; quotes: auto; r: 0px; resize: none; rotate: none; ruby-align: space-around; ruby-position: over; rx: auto; ry: auto; scale: none; scroll-behavior: auto; scroll-margin-block: 0px; scroll-margin: 0px; scroll-margin-inline: 0px; scroll-padding-block: auto; scroll-padding: auto; scroll-padding-inline: auto; scroll-snap-align: none; scroll-snap-stop: normal; scroll-snap-type: none; scroll-timeline: none; scrollbar-color: auto; scrollbar-gutter: auto; scrollbar-width: auto; shape-image-threshold: 0; shape-margin: 0px; shape-outside: none; shape-rendering: auto; speak: normal; stop-color: #000000; stop-opacity: 1; stroke: none; stroke-dasharray: none; stroke-dashoffset: 0px; stroke-linecap: butt; stroke-linejoin: miter; stroke-miterlimit: 4; stroke-opacity: 1; stroke-width: 1px; tab-size: 8; table-layout: auto; text-align: left; text-align-last: auto; text-anchor: start; text-combine-upright: none; text-decoration-line: none; text-decoration-style: solid; text-decoration-color: #000000; text-decoration-skip-ink: auto; text-emphasis: none #000000; text-emphasis-position: over; text-orientation: mixed; text-overflow: clip; text-rendering: auto; text-shadow: none; text-spacing-trim: normal; text-underline-offset: auto; text-underline-position: auto; white-space: pre-wrap; timeline-scope: none; touch-action: auto; transform: none; transform-box: view-box; transform-origin: 0px 0px; transform-style: flat; transition: all; translate: none; unicode-bidi: normal; user-select: text; vector-effect: none; vertical-align: baseline; view-timeline: none; view-transition-class: none; view-transition-name: none; visibility: visible; border-block: 0px none #000000; border-inline: 0px none #000000; block-size: auto; margin-block: 0px; margin-inline: 0px; max-block-size: none; max-inline-size: none; min-block-size: 0px; min-inline-size: 0px; padding-block: 0px; padding-inline: 0px; width: auto; will-change: auto; word-break: normal; writing-mode: horizontal-tb; x: 0px; y: 0px; z-index: auto; zoom: 1; border: 0px none #000000;\u0022 xml:lang=\u0022EN-US\u0022 data-contrast=\u0022auto\u0022\u003e\u003cspan class=\u0022NormalTextRun SCXW146580512 BCX8\u0022\u003ePlease select your top three preferred referral pathways\u003c/span\u003e\u003c/span\u003e","instruction":"\u003cspan class=\u0022TextRun SCXW205551965 BCX8\u0022 style=\u0022accent-color: auto; place-content: normal; place-items: normal; place-self: auto; alignment-baseline: auto; anchor-name: none; animation: 0s ease 0s 1 normal none running none; animation-composition: replace; app-region: none; appearance: none; aspect-ratio: auto; backdrop-filter: none; backface-visibility: visible; background: none 0% 0% / auto repeat scroll padding-box border-box rgba(0, 0, 0, 0); background-blend-mode: normal; baseline-shift: 0px; baseline-source: auto; 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font-size: 16px; color: #7e8c8d;\u0022\u003e\u003cspan class=\u0022TextRun SCXW261208365 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;\u0022 xml:lang=\u0022EN-US\u0022 data-contrast=\u0022auto\u0022\u003e\u003cspan class=\u0022NormalTextRun SCXW261208365 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text;\u0022\u003eRarely (1 a month or less)\u003c/span\u003e\u003c/span\u003e\u003cspan class=\u0022EOP SCXW261208365 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;\u0022 data-ccp-props=\u0022{}\u0022\u003e聽\u003c/span\u003e\u003c/span\u003e","rightText":null,"fieldName":"q7","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"5","score":null,"text":"\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif; font-size: 16px; color: #7e8c8d;\u0022\u003e\u003cspan class=\u0022TextRun SCXW96932861 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;\u0022 xml:lang=\u0022EN-US\u0022 data-contrast=\u0022auto\u0022\u003e\u003cspan class=\u0022NormalTextRun SCXW96932861 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text;\u0022\u003eNever (no referrals in 6+ months)\u003c/span\u003e\u003c/span\u003e\u003cspan class=\u0022EOP SCXW96932861 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; text-align: left; white-space: pre-wrap; background-color: #ffffff; line-height: 20.5042px;\u0022 data-ccp-props=\u0022{}\u0022\u003e聽\u003c/span\u003e\u003c/span\u003e","rightText":null,"fieldName":"q7","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""}],"answerGroups":[],"readOnly":false,"required":true,"category":"","validationRules":[{"type":"Required","message":"Please select an answer.","validateOnBackwardNavigation":false}],"questionId":"q7","title":"How Often Refer","text":"\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003e\u003cspan class=\u0022TextRun SCXW545508 BCX8\u0022 style=\u0022margin: 0px; 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padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003eIs there anything else you would like to share about your referral experience?\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW112356565 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e \u003c/span\u003e\u003c/span\u003e","instruction":"","errorMessages":[],"nodeType":"OpenText","customRendering":false,"triggeredQuestions":[],"isRtl":false,"isAccessible":false,"customQuestion":null,"isCatiReviewingMode":false},{"rows":0,"columns":0,"maxLength":null,"multiCount":{"equal":null,"min":null,"max":null},"multiSum":null,"inputAffix":{"prefix":"","suffix":""},"answersHaveRightText":false,"layoutRows":0,"layoutColumns":0,"noResponseAnswers":[],"noResponseValue":null,"values":{},"otherValues":{},"answers":[{"code":"1","score":null,"text":"Email Address","rightText":null,"fieldName":"q12_1","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""},{"code":"2","score":null,"text":"NPI Number","rightText":null,"fieldName":"q12_2","otherFieldName":null,"other":null,"isOther":false,"isExclusive":false,"groupCode":null,"imagesSettings":null,"styleName":"","backgroundColor":""}],"answerGroups":[],"readOnly":false,"required":false,"category":"","validationRules":[],"questionId":"q12","title":"Advisory Council","text":"\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003e\u003cspan class=\u0022NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003eWould you \u003c/span\u003e\u003cspan class=\u0022NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003ebe interested in joining an online advisory council where you will have \u003c/span\u003e\u003cspan class=\u0022NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003ean opportunity\u003c/span\u003e\u003cspan class=\u0022NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e to provide feedback and receive regular updates on improvements to our \u003c/span\u003e\u003cspan class=\u0022NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003eprocesses, including how you refer your patients to us\u003c/span\u003e\u003cspan class=\u0022NormalTextRun AdvancedProofingIssueV2Themed SCXW34082942 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; background-position: 0px 100%; background-repeat: repeat-x; background-image: var(--urlAdvancedProofingIssueV2,); border-bottom: 1px solid transparent; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e? \u003c/span\u003e\u003c/span\u003e","instruction":"\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003e\u003cspan class=\u0022NormalTextRun SCXW197219248 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003eIf yes, please provide\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW197219248 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e your\u003c/span\u003e\u003cspan class=\u0022NormalTextRun SCXW197219248 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; font-size: 16px; text-align: left; white-space: pre-wrap; background-color: #ffffff;\u0022\u003e email address / NPI #\u003c/span\u003e\u003c/span\u003e","errorMessages":[],"nodeType":"OpenTextList","customRendering":false,"triggeredQuestions":[],"isRtl":false,"isAccessible":false,"customQuestion":null,"isCatiReviewingMode":false},{"questionId":"i13","title":"Thank you","text":"\u003cspan style=\u0022font-family: \u0027Helvetica Neue\u0027, Helvetica, Arial, sans-serif;\u0022\u003e\u003cspan class=\u0022TextRun SCXW90568000 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text; color: #000000; text-align: left; white-space: pre-wrap; background-color: #ffffff; font-size: 12pt; line-height: 20.5042px;\u0022 xml:lang=\u0022EN-US\u0022 data-contrast=\u0022auto\u0022\u003e\u003cspan class=\u0022NormalTextRun SCXW90568000 BCX8\u0022 style=\u0022margin: 0px; padding: 0px; user-select: text;\u0022\u003eThank you again for your participation in this survey. We are committed to using your feedback to improve our referral process and strengthen our partnership with you. 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