RRPF Medical Practitioner Survey

Return email Address:   

Person submitting form:

Today's Date: (mm-dd-yy)

If this is the first time that you have completed an RRPF Practitioner survey, check here     

If this is an update for a medical practice already registered with the RRPF check here
(Only provide your name and that information you wish to update)

Names and Phone Numbers:

Doctor Name:  

Medical Practice Name:

Address Line 1:     

Address Line 2:     

City:        State:        Zip:

Phone:     (area code-number)

Fax Number: 

E-Mail Address:   

If this is a new address check here               

Surgical approach used  (select all that apply) : no entry CO2 Laser Micro deBrider Cold Steel Other
                                Other surgical approach:             

Patient population information:

Total number of RRP patients in your practice

Male patients   Female patients

Pediatric   Adult

RRP patient surgical frequency information:

Number of patients requiring surgery MORE frequently than every 2 months

Male    Female

Number of patients requiring surgery between 2 and 12 months

Male    Female

Number of patients requiring surgery LESS frequently than every year

Male    Female

Adjunct therapy treatment information:

Please indicate the number of patients being (or that have been) treated with the following:

Interferon   

I3C    or DIM   

Cidofovir   

PDT   chemical agent:   

Mump Vaccine   

Accutane   

Acyclovir   

Other   specify:   

Additional Comments:   

Thank you for taking the time to complete this survey.        

You may want to print out a hardcopy of this form as a backup for your records, before submitting        

Please confirm your submission by sending e-mail to bills@rrpf.org