POZ Health Information Poster Acceptance Form

Real Health HIV Prevention Health Information Poster Acceptance Form
A limited number of Real Health HIV Prevention 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 Real Health HIV Prevention 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.

Real Health HIV Prevention Health Information Poster Acceptance Form