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Doctor Questionnaire

Office Email

e

Practice Name

e

Address

e

City

e

State

e

Zip Code

37010

Office Phone

e

First Name

Dr

Last Name

E

Degree

DDS

Area of Practice

General Dentist

Experience

20+ years

Languages Spoken

English

URL

https://wewe.com

Has your license to practice in this state or any other state been denied, restricted, limited, suspended or revoked; have you ever been reprimanded by a state licensing agency; or are any of these actions pending with respect to your license?

No

Has your DEA Registration ever been restricted, limited, suspended or revoked, or are any of these actions pending with respect to your DEA Registration?

Yes

Have your hospital privileges, if any, ever been revoked, suspended, reduced, or not renewed; have disciplinary proceedings ever been instituted against you; or are any of these actions now pending with respect to your hospital privileges?

No

Have you ever voluntarily relinquished hospital privileges, DEA Registration, academic appointments or any other professional status while an investigation was conducted?

No

Unknown Question

Yes

Unknown Question

Yes

Have any professional claim settlements, not involving litigation or arbitration, been paid by you or paid on your behalf?

No

Has your professional liability insurance ever been canceled or has professional liability insurance ever been denied?

Yes

Have you ever been convicted of a felony or do you have any felony or misdemeanor charges pending (other than minor traffic offenses)?

No

Do you now have or have you had a chemical dependency/substance abuse problem?

Yes

Malpractice Document

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State Dental License

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ELECTRONIC SIGNATURE & AGREEMENT