Dear ,

is looking to join Luna Care, Inc and has provided your name as a professional reference. In order to process their credentials, the following information regarding their clinical performance is required:

1. I have been professionally affiliated with them from
   to
2. My knowledge of the applicant's competence is based on:
   Peer/Colleague
   Program Director/Direct Supervisor
   Other (such as referring Physician):
3. Please review and answer the question below based on your personal observations.

   	Satisfactory	Unsatisfactory	Not Observed
   1. Communication abilities with patients and colleagues	Satisfactory	Unsatisfactory	Not Observed
   2. Technical skills and competence	Satisfactory	Unsatisfactory	Not Observed
   3. Professionalism	Satisfactory	Unsatisfactory	Not Observed
   4. Charting & documentation	Satisfactory	Unsatisfactory	Not Observed
   5. Personal judgment	Satisfactory	Unsatisfactory	Not Observed
   6. Ethical conduct	Satisfactory	Unsatisfactory	Not Observed
   7. Work habit	Satisfactory	Unsatisfactory	Not Observed
   8. Patient rapport	Satisfactory	Unsatisfactory	Not Observed