LaVidaCare Patient Intake Form

Questionnaire for Ad Participants

LaVida Care - SFCHC HIV Prevention Program
Your name will not be used without your permission. Contact details are for internal purposes only (to schedule photos, send information, confirm your permissions, ask you additional questions).
Patient Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone numberFormat: (000) 000-0000.
- Is it OK to include your name in the ad? If so, how? (First name only, first name and last initial, initials only, no name, handle, pseudonym, etc.)
- What identity is important to you? Answer this any way you like — gender, cultural, familial, professional? Feel free to include more than one identity.
- What do you aspire to? What do you want to do in the future?
- What food says “love” to you?
- What do you hope for?
- What inspires you?
- What makes you happy?
- In what way has this program helped you manage your health?
- If you'd like, write your own question and answer here:
- PERMISSION TO USE PHOTOGRAPH
- Event:
- Location:
- PLEASE NOTE: Patient or parent/guardian (if patient is under age 18) must provide an electronic signature below. Use your mouse, finger, or stylus to sign in the space provided.
  
  I grant to San Fernando Community Health Center, the right to take photographs of me or my child in connection with the above-identified event. I authorize San Fernando Community Health Center, its assigns and transferees to copyright, use and publish the same in print and/or electronically.
  
  I agree that San Fernando Community Health Center may use such photographs of me or my child with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
  
  I have read and understand the above.
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Signature
- Please verify that you are human
- Should be Empty:

Questionnaire for Ad Participants