Become a Sexual Health Advocate
Promote sexual health awareness in your clinic
Submit
Your Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Organization
*
The name of your clinic/practice
What is Your Profession
*
Family Physician
Nurse Practitioner
Nurse
Urologist
Gynecologist
Physician - Other
Psychologist
Social Worker
Nurse Psychotherapist
Registered Psychotherapist
Administrator
Pelvic Floor Physiotherapist
Naturopath
Chiropractor
Other
If "other", please specify
Indicate your profession
Request Promotional Material
Please indicate which complimentary promotional material you would like to order for your clinic
Please select the promotional material you would like
Tri-fold brochures
Wall posters
Business cards
Referral forms to fax
Information booklet about the referral process for me or my team
Other
Please select the type and quantity of promotional material
Rows
Quantity
Tri-fold brochures for patients
<10
10
50
100
200
I don't know
Wall posters
<10
10
50
100
200
I don't know
Business cards
<10
10
50
100
200
I don't know
Referral forms
<10
10
50
100
200
I don't know
Referral Information booklet for health care providers
<10
10
50
100
200
I don't know
If you'd like other promotional material, please specify type and amount:
Please indicate where we should send these material
Mailing Address
Street Address
Street Address Line 2
City
Province
Postal Code
Please indicate who we should address the package to
Name
First Name
Last Name
Position
What is the position/title of the person who will receive the package
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Request Training
Please indicate the type of training you would be interested in
Lunch & Learn (1-2 hrs)
Full Day Workshop (5 hrs)
Two Day Workshop (10 hrs)
Individual Consultation (30 min - 1 hr)
Other
Training can be highly customizable, based on your learning objectives. Please use the space below to indicate what you are hoping to achieve with training.
Should be Empty: