Thank you for filling out our Healthcare Practitioner Inquiry form. This form will help guide the types of programs AboutFace and Trailblazers offers in the future. All questions are mandatory unless otherwise noted. 

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* 1. Name:

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* 2. Occupation:

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* 3. Institution/Organization:

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* 4. Please provide us with the following contact information:

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* 5. Are you interested in receiving updates about programs and services through our bi-monthly newsletter? 

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* 6. On average, how often do you see your patients?

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* 7. What do your patients say is their primary concern?

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* 8. What do your patients say some of their ongoing/additional concerns are? (You can pick up to 3 options)

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* 9. What types of support do your patients frequently ask for? 

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* 10. What are some barriers your patients face that are unique to your location?

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* 11. What types of programs do you think AboutFace should provide to benefit your patients? (You can pick up to 2 options)

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