Information-keep – Diabetes Guardians

Name
Credentials (MD, DO, DPM, PA, NP, RN)
License Number & State
Primary Specialty / Role
Institution
Practice Setting (FQHC / Rural / Other) (Check all that apply)
Federally Qualified Health Center (FQHC)Rural Health ClinicSafety-Net / Community ClinicTribal Health ProgramPublic Hospital / County SystemPrivate PracticeOther
Nature of Request
Contact information EMAIL

A. Practice Environment

Do you currently have regular access to podiatric specialty care?
YesLimitedNo
Approximate percentage of patients with diabetes in your practice:
<10%10–20%>20%
Does your facility have plans to recruit podiatric services in the near future?
YesNo

B. Nature of Request

(Select primary focus)

Educational discussion of diabetic foot complicationsLimb preservation strategiesRisk-stratified care frameworksProgrammatic or workflow considerationsImplementation questions for underserved or rural settings

Brief Description of Request (no patient identifiers)

C. Acknowledgment

I confirm that I am a licensed healthcare professional.I understand this request is for educational peer-to-peer consultation only and does not involve direct patient care.I acknowledge that no physician–patient relationship is established.

D. Contact Information

Email Address
Phone (optional)