HAN Sign Up Form

Larimer County Health Alert Network

Please complete this form to enroll in the Larimer County Health Alert Network system.
Please complete all information below:
First Name:*
Last Name*
Title
Agency/Organization*
Which option(s) best describe your organization?

Alternative MedicineAnimal Control/Boarding/RescueChiropractorsChildcareCorrectionsDentalDialysisEmergency ManagementEmergency RoomFirst Responder (Law Enforcement, EMS, Fire)Home Health and HospiceHomelessness Service ProviderHospitalInfection ControlLong-Term Care FacilityMedical SpaMental and Behavioral HealthOB/GYNsOptometryPathologyPediatricsPharmacyPhysical Therapy/RehabPrimary Care ProviderSchool HealthSurgery CenterTattoo and/or Piercing FacilityUrgent CareVeterinaryOther
E-mail:*
I would like to receive emails from LCDHE outside of the Health Alert Network about training opportunities and other less urgent public health information.

YesNo
Work Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
I would like to receive Health Alert Network messages via text.

YesNo
Fax:

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Should be Empty:

Larimer County Health Alert Network