Request for Help with Finding a Doctor

Request for Help with Finding a Doctor

CALIFORNIA RESIDENTS - Please complete information below and a Community Health Worker will follow up with you. If you have questions please send an email to deborahg@scdfc.org or call the SCDF at (909) 743-5226.
OUTSIDE OF CALIFORNIA - We will try to help as best we can. Please allow up to 10 days for us to get back to you.
This form is HIPAA compliant and all information provided is confidential. For a copy of our HIPAA Notice of Privacy Practices, click here.
Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Age Range of person with SCD:
Contact Number:
Format: (000) 000-0000.
E-mail

Confirmation Emailexample@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current type of insurance:
What type of doctor are you looking for?
Would you like to receive information on the following therapies for people with SCD?

Other
Comments/Questions:
Should be Empty: