Clinic Contact Information

Name of individual completing survey (include your professional credentials, such as MD, RN, MSW, MPH):

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* 1. Name of individual completing survey (include your professional credentials, such as MD, RN, MSW, MPH):

Clinic:

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* 2. Clinic:

Clinic (physical) Address:

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* 3. Clinic (physical) Address:

City, State, ZIP code:

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* 4. City, State, ZIP code:

Clinic Mailing Address (if different from above):

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* 5. Clinic Mailing Address (if different from above):

City, State, ZIP code:

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* 6. City, State, ZIP code:

Phone number:

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* 7. Phone number:

Clinic e-mail address:

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* 8. Clinic e-mail address:

Executive Director Name:

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* 9. Executive Director Name:

Executive Director e-mail address:

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* 10. Executive Director e-mail address:

Alternate Contact (name/title):

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* 11. Alternate Contact (name/title):

Alternate Contact e-mail address:

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* 12. Alternate Contact e-mail address:

Clinic Website:

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* 13. Clinic Website:

Please verify that OAFC website information for your clinic is correct (under Find A Clinic): http://ohiofreeclinics.org/who-we-are/locations/find-a-clinic.html. List any corrections below:

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* 14. Please verify that OAFC website information for your clinic is correct (under Find A Clinic): http://ohiofreeclinics.org/who-we-are/locations/find-a-clinic.html. List any corrections below:

 
7% of survey complete.

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