Physician Providers Professional Reference Form

Introduction*
Recently an individual expressed an interest in working as a locum tenens physician with our company and listed you as a reference. Please take a moment to complete this form. This is a professional reference request, so please answer the questions to the best of your knowledge. Please initial below to indicate you have read this and understand the purpose of this form. Thank you in advance for your assistance.
Information About You*
Please type your first and last name below.
Prefix First Last
Specialty
What is your practicing specialty?
Email
Phone
Providing a Professional Reference for:*
First Last
How would you rate the physician's clinical skills?*
Please choose one of the following
Please explain
If you answered Poor or Unsatisfactory for the previous question, please take a moment to explain in the space provided below.
How would rate the physician's interpersonal skills with the patients?*
Please choose one of the following
Please explain
If you answered Poor or Unsatisfactory for the previous question, please take a moment to explain in the space provided below.
How would you rate the physician's interpersonal skills with the staff?*
Please choose one of the following
Please explain
If you answered Poor or Unsatisfactory for the previous question, please take a moment to explain in the space provided below.
Do you know if this healthcare provider has any personal problems that would affect his/her performance?*
Please choose one of the following
Please explain*
If you answered Yes or Sometimes for the previous question, please take a moment to explain in the space provided below
Would you have this physician treat you and your family?*
Please choose one of the following
Would you have this physician fill in for you or cover your practice?*
Please choose one of the following
Additional Comments
If you answered "Poor" or "Unsatisfactory" for any question(s), please use the space below to explain.
Signature*
Date*
Date Format: MM slash DD slash YYYY
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