Site Visit Form

Welcome to the Site Visit Form. Please complete the following information for each hospital visited.

If follow-up is requested, please be sure to indicate which team member is to follow-up and Stacy will create a reminder.

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Name: *

First

Last

Email *

Hospital Location Represented:RichmondFrederickBoth

Service(s) Discussed:

• Hospital-wide / General Partner services
• ER & Critical Care
• Neurology
• Internal Medicine
• Oncology
• Surgery
• Urgent Care

Date of Visit: *

Hospital Visited: *

Visit Type: *

• Site Visit
• Materials Drop-Off (by request)
• CE/Event Flyer Drop-Off
• Holiday Gift Delivery

Today I spoke with: *

Role:Front DeskPractice ManagerSupport Staff (LVT, Assistant, ect)DVMOther

Additional Team Members Met (if applicable):

How well do they know Partner?4321

Time Spent:<15 min15 – 30 min30 – 60 min

Materials Shared:

• Know Before You Go
• Business Cards
• Magnets
• Pens
• Window Cling
• Specialty Piece
• CE/Event Flyer
• Staff treats (cookies, muffins, etc.)
• Other (please describe below)

Other materials shared:

Overall Tone of Visit:

• Very Positive
• Neutral
• Mixed
• Concerning

Unique Follow Up Required?

• Yes
• No

Follow-Up Type:

• Email
• Phone call
• Return visit
• Leadership follow up

Assigned To:KelleyStacyChristyJulie

Current Clinic Email Address:

Notes:

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