The Daniels Group

Physician Call Questionnaire

Doctors Name *
Home Phone *
Group Name *
What information do you want our attendants to get from callers?
Please number each item and hit return after each:
Information *
Do you take after hour calls from anyone or just regular patients?
After Hour Calls? *	Regular Patients Only Anyone
Pager Number *
What type of pager do you use? (voice, number display, tone, alphanumeric)
Pager Type? *
What paging procedures do you prefer? *
What form(s) of after hour call notification (page, patched calls, call residence, call hospital or hold for office) do you wish to use for the following types of calls?
Emergency/Urgent: *
Prescription: *
Consult: *
Personal: *
Other: *
Will you call us when you go off pager or do you want it on a regular schedule?
Off Pager? *	I will call in Follow schedule
Will your office mail,fax or email an on-call schedule?
Schedule: *	Mail Fax Email
At what interval? *
What is the time schedule for on-call changes?
Monday - Friday? *
Saturday, Sunday & Holiday? *
Do you want us to give your residence number to others? (check the box below if "yes")
Physcians who request it?
Hospitals?
Patients?
Between 7AM and office opening, do you want us to call your residence first or page you?
Before hours: *	Call Residence Page
Do you accept calls from inpatients or do you require a call from the RN?
I accept calls: *	From Inpatients From RN Only
Do you accept calls from family members of inpatients? (check yes or no)
Calls from Inpatient Family Members? *	Yes No
Will you accept a call from another Doctor if you are NOT on call?
Calls From Another Dr.? *	Yes No
Do you have a Physcians Assistant? *	Yes No
If yes, list on-call procedures to follow for him/her:
PA on-call procedures:

* required field