Healthcare Secret Shopper Profile

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General Information

First Name:

Last Name: *

Street Address: *

City: *

State: *

Zip Code: *

Email Address: *

Phone: *

Additional Information

Do you have daily access to a computer?: *

Are you currently employed or have you ever been employed by a healthcare organization? *

If yes, please explain: *
(what? / when?)

Have you ever been convicted of a felony? *

If yes, please explain: *
(what? / when?)

How did you hear about us?

Optional Information (Some “special projects” require shoppers who fill certain criteria, e.g., age, certain medical conditions. If you would like us to consider you for these “special projects”, please provide the information below.)

Age

Gender

Medical Conditions
(e.g., diabetic, pregnancy, cardiac)

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Call us 877.546.0970