Recommended Resource
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My Connection to TS
Health Provider
Self
Researcher
Caregiver
Administrator
Spouse
Government
Friend
Colleague
None
My Name
*
Dr.
Ms.
Mrs.
Mr.
Prefix
First Name
Last Name
Suffix
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best way to contact me
*
Phone
Email
Mailing
Recommendation
Physician, Agency, Learning Center, Resource
Health Provider's Name
*
Dr.
Ms.
Mr.
Prefix
First Name
Last Name
Suffix
Rate
1
2
3
4
5
Provider Specialty: Pediatric, Adult, Surgeon
Your experience- Explain reason for your referral
Other:
Provider Email
*
example@example.com
Provider Phone Number
*
Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best way to contact medical care provider
*
Phone
Email
Mailing
Would you suggest this resource specific to TS be referred to others via the TSF State Map?
*
Yes
No
Already on the map
I do not know
Name of Company - health, education, government, business referral
How are you affiliated?
Recommend another one?
Yes
No
2. Health Provider's Name
*
Dr.
Ms.
Mr.
Prefix
First Name
Last Name
Suffix
2. Rate
1
2
3
4
5
2. Provider Specialty: Pediatric, Adult, Surgeon
2. Your experience- Explain reason for your referral
2. Other:
2. Provider Email
*
example@example.com
2. Provider Phone Number
*
2. Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2. Best way to contact medical care provider
*
Phone
Email
Mailing
2. Would you suggest this resource specific to TS be referred to others via the TSF State Map?
*
Yes
No
Already on the map
I do not know
2. Name of Company - health, education, government, business referral
2. How are you affiliated?
Recommend another one?
Yes
No
3. Health Provider's Name
*
Dr.
Ms.
Mr.
Prefix
First Name
Last Name
Suffix
3. Rate
1
2
3
4
5
3. Provider Specialty: Pediatric, Adult, Surgeon
3. Your experience- Explain reason for your referral
3. Other:
3. Provider Email
*
example@example.com
3. Provider Phone Number
*
3. Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3. Best way to contact medical care provider
*
Phone
Email
Mailing
3. Would you suggest this resource specific to TS be referred to others via the TSF State Map?
*
Yes
No
Already on the map
I do not know
3. Name of Company - health, education, government, business referral
3. How are you affiliated?
Recommend another?
Yes
No
4. Health Provider's Name
*
Dr.
Ms.
Mr.
Prefix
First Name
Last Name
Suffix
4. Rate
1
2
3
4
5
4. Provider Specialty: Pediatric, Adult, Surgeon
4. Your experience- Explain reason for your referral
4. Other:
4. Provider Email
*
example@example.com
4. Provider Phone Number
*
4. Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
4. Best way to contact medical care provider
*
Phone
Email
Mailing
4. Would you suggest this resource specific to TS be referred to others via the TSF State Map?
*
Yes
No
Already on the map
I do not know
4. Name of Company - health, education, government, business referral
4. How are you affiliated?
I want to organize a center of care in my area
Yes
No
Patient care available at this Center
Pediatric care
Transitioning care coordinator
Adult care
I am interested in facilitating any or all of the following:
Hosting a patient workshop with TSF
Becoming a leader, speaker, advisor
Submitting news or announcements for website or newsletter
Submitting research or clinical studies
Other
Would you like to receive the TSF professional office kit for a $50.00 donation?
*
Yes
No
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