POZ Health Information Poster Acceptance Form

Hep Hepatitis C Health Information Poster Acceptance Form
A limited number of Hep Hepatitis C Health Information Posters are available on a first-come, first-served basis. To have one or more installed in your office, indicate your acceptance by completing the form below.
I wish to receive (quantity) FREE Hep Hepatitis C Information Poster(s) for my office.
Contact name:

First NameLast Name
Contact title:
Contact phone:

Area CodePhone Number
Contact email:
Organization:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Approximate number of client visits per month
Number of waiting rooms
Number of doctors (if any)
Type of office (choose one)

AIDS Clinical Trial UnitAIDS Service OrganizationClinicCommunity-Based OrganizationComplementaryTherapyPracticeDoctorDrug Treatment CenterEducational InstitutionFaith-Based OrganizationGovernment-Based OrganizationGrant FoundationHospitalHousing ProviderLegal CounselLGBTQIA CenterPharmacyPrison or Prison Outreach ProgramOther

If you would like to receive complimentary copies of our magazines for your office, please indicate the quantity.

Hep Hepatitis C Health Information Poster Acceptance Form