1. E-mail address:

2. Name:

3. How would you describe yourself? (Click on one choice)
Health Care Provider
Health Sciences Student
Patient (patient's family member or friend)
Other:

4. What country are you from?

SECTION B
Please tell us about Virtual Hospital:

5. What do you like about Virtual Hospital? (Briefly describe)

6. What do you dislike about Virtual Hospital? (Briefly describe)

7. How would you improve Virtual Hospital? (Briefly describe)

8. To you, how valuable is Virtual Hospital? (Click on one choice)
1 - Extremely valuable
2 - Very valuable
3 - Valuable
4 - Somewhat valuable
5 - Not at all valuable

9. Other comments and/or questions about Virtual Hospital? (Briefly describe)

Finally:

10. What other medical Web sites do you use, and why do you use them? (Briefly describe)

Please click the "Send" button to complete this form.