Medically Tailored Meals Questionaire
This short form makes it simple to determine eligibility for FISH's Healthy Table program. This does not guarantee or authorize qualification for our services.
Do you have a diagnosis of any of the following health conditions
*
Cardiovascular disease
Diabetes/pre-diabetes
Chronic kidney disease
I have not been diagnosed with any of these conditions
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Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Home Phone or Alternate Phone Number
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a consistent delivery address?
Yes
No
Do you have consistent access to a freezer?
Yes
No
Do you have consistent access to a microwave or oven?
Yes
No
Do you consent to receive text messages from the Medically Tailored Meals team?
Yes
No
Do you agree to stay in communication with the Medically Tailored Meals team in regards to meal distribution and education opportunities?
Yes
No
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Thank you for your submission. Unfortunately, you don't currently have a qualifying diagnosis.
Would you like to join our mailing list to learn more about our programs?
example@example.com
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Would you like to join our mailing list to learn more about our programs?
example@example.com
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Should be Empty: