Name for your donation letter

Email Address

What is your gender? What is your gender? Female Male Other

Please check the single box that describes you best. Please check the single box that describes you best. Obstetrician and/or Gynecologist Primary Care Physician Family Medicine Practitioner Nurse Practitioner Physician's Assistant Midwife None of the above

I routinely use ICD-10-CM Diagnosis Code Z30.430 "Encounter for insertion of intrauterine contraceptive device." I routinely use ICD-10-CM Diagnosis Code Z30.430 "Encounter for insertion of intrauterine contraceptive device." Yes No

I spend greater than 60% of my time in direct patient care. I spend greater than 60% of my time in direct patient care. Yes No

I provide sexual & reproductive health care in-office to greater than 10% of my patients. I provide sexual & reproductive health care in-office to greater than 10% of my patients. Yes No

Would you recommend QS permanent contraception to your patients if it was FDA approved? Would you recommend QS permanent contraception to your patients if it was FDA approved? Yes No

Would the lower cost of QS compared to other methods positively influence your decision? Would the lower cost of QS compared to other methods positively influence your decision? Yes No

Would you like to participate in QS permanent contraception FDA clinical trials? Would you like to participate in QS permanent contraception FDA clinical trials? Yes No

Please ask and answer the most important question we forgot to ask.