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1. First Name

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2. Last Name

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3. Email Address

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4. Primary Phone Number

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5. Clinic/Practice Name

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6. Clinic/practice State

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7. Clinic/Practice City

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8. Is your Clinic/Practice a non-profit organization?

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9. What percentage of your patient base receives care at a reduced or free rate?

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i We adjusted the number you entered based on the slider’s scale.

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10. Please explain how your clinic serves those in need.

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11. Please describe how the free food sensitivity tests would be used within your practice/clinic.

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12. Is there anything else you would like us to know or to take into consideration?

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13. Clinic/Practice Website URL

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