Request edit access
Sign up to receive the patient education brochure and companion poster on extreme heat
Full Name and Credentials *
Your answer
Title and Organization *
Your answer
Email Address *
Your answer
City and State *
Your answer
How will you use the brochure? *
Required
Approximately how many patients do you plan to educate using this material?
Your answer
Please tell us a bit more about how you plan to use the brochure and companion poster (optional).
Your answer
Yes, I am interested in providing patients who read the brochure with a brief survey to assess its effectiveness.
Submit
Never submit passwords through Google Forms.
This form was created inside of Health Care Without Harm. Report Abuse - Terms of Service