Liaison Visit Log

Please ask as many of these questions as possible during your follow-up conversation with healthcare providers. We are using this feedback for program evaluation; therefore please provide responses that are as specific as possible.

Liaison Name:*
Date:*
Healthcare Provider Name:*
Title:
HCP Organization:
Address:
Phone number:*
Email:*
  1. Have you utilized the acrylic display to showcase ABCD materials?
    YesNo
  2. How likely are you to refer your patients to ABCD using our online referral portal? What barriers prevent you from doing so?
    Very LikelyLikelyNeutralUnlikelyVery Unlikely
  3. Will you be adding our materials to new patient folders?
    YesNo
  4. Which materials did you find most useful?
5. How can ABCD better serve you and your patients?
6. Who else should we be contacting?
7. Materials Requests?
8. Additional Questions?

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