Join the Network

Clinic/Practice Name*

Parent Group/Organization Name

Clinic/Practice Website *

Administrative Point of Contact *

Administrative Email Address*

Administrative Phone Number *

Provider Point of Contact

Provider Email Address

Provider Phone Number

Please select the technology services available to you at your clinic/practice:

Do you collaborate with other practices in your area, either for medical or research purposes?

Does your clinic/practice use electronic medical records?

If your practice utilizes EMR, which vendor do you use?

Does your clinic/practice currently participate in research? Select all that apply.

Do you utilize patient registries?

Has your clinic/practice experienced any of the following barriers in conducting/participating in research? Select all that apply.

Funding
Not enough time/bandwith
Not enough clinic support (research coordinators, research assistants, data management)
Lack of training
Other
None