Physician Registration Form

Please complete the following on-line profile so we can locate various types of focus groups that may suit your interests. If you have any questions, please feel free to call us at: Fieldwork East, Fort Lee 201-585-8200. Your demographic information is kept in strict confidentiality!

(Fields marked with an asterisk "*" are required)

We have offices in Fort Lee, NJ and NYC. Select which office(s)

where you would like to participate:


First Name:


Last Name:





Cell: 1-

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Office: 1-

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Home: 1-


Fax: 1-


Date of Birth:




Medical Specialty
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Healthcare Title:


Board eligible or board certified:


Primary Practice Setting


Practice / Office Name:


Hospital Affiliation:

Please list your weekday availability for market reseasch groups
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Monday Tuesday Wednesday Thursday Friday

Work State:


Work City:


Home State:

Home City:

What are my responsibilities as a focus group participant?

Fieldwork and its clients rely on the integrity of focus group respondents to conduct accurate and meaningful research.

We ask that you commit to the following:

  • Providing your personal information to Fieldwork constitutes your express written consent for collection, storing and processing your personal information.
  • You have read and agree to the terms in our Privacy Policy.
  • Be truthful in answering questions about yourself and your habits. You certify all information provided is accurate as of the date of your offering the information either electronically, on paper, or verbally.
  • Arrive for your appointment at least 15 minutes early and be ready to fully participate in the discussion.
  • Understand that anyone arriving late for their appointment may not be admitted into the study or be compensated.
  • Notify Fieldwork if you must cancel with as much advance notice as possible. Both Fieldwork and our clients s are depending on your participation, and while we understand that circumstances may come up forcing you to cancel, with advance notice, we have the opportunity to try to recruit another interested participant.
  • Enjoy & contribute to the discussion! Focus Groups are fun and your opinions count!
Your voluntary participation in Market research with Fieldwork constitutes an Independent Contractor relationship, not an Employment relationship.

If at any time you wish to unsubscribe from our database, you may call the office you signed up with or fill out this unsubscribe form.

Panelists under the age of 18 must have a Parent or Guardian's permission to register and participate.

*  I have read and understand my responsibilities as a participant and I agree to the terms and conditions above.