Clinic Contact Information

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

* 2. Clinic:

* 3. Clinic (physical) Address:

* 4. City, State, ZIP code:

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

* 6. City, State, ZIP code:

* 7. Phone number:

* 8. Clinic e-mail address:

* 9. Executive Director Name:

* 10. Executive Director e-mail address:

* 11. Alternate Contact (name/title):

* 12. Alternate Contact e-mail address:

* 13. Clinic Website:

* 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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