Section 1 of 1
Tomales Osteopathic Free Clinic - For Osteopathic Premeds, Students & Physicians only
Signup for osteopathic premeds, students, & physicians who would like to participate in the clinic --
We will be meeting at Tomales Deli and Cafe (27000 Shoreline Hwy, Tomales, CA 94971) at 5:15 pm to enjoy dinner together before setting up the clinic at 6:30.
The clinic will run from 7-9 pm at Tomales Town Hall (27150 Maine St, Tomales, CA 94971) in the basement. There is ample parking in this area, but little to no cell service. The town hall is a big red building in the small downtown of Tomales.
We will have 3 treatment tables set up, with 1-2 osteopathic students/physicians at each of them. We will see a total of 6 patients - from 7-8 pm and 8-9 pm. They will complete a registration form, undergo a patient intake with you, and receive a 30-40 minute osteopathic treatment.
We will be meeting at Tomales Deli and Cafe (27000 Shoreline Hwy, Tomales, CA 94971) at 5:15 pm to enjoy dinner together before setting up the clinic at 6:30.
The clinic will run from 7-9 pm at Tomales Town Hall (27150 Maine St, Tomales, CA 94971) in the basement. There is ample parking in this area, but little to no cell service. The town hall is a big red building in the small downtown of Tomales.
We will have 3 treatment tables set up, with 1-2 osteopathic students/physicians at each of them. We will see a total of 6 patients - from 7-8 pm and 8-9 pm. They will complete a registration form, undergo a patient intake with you, and receive a 30-40 minute osteopathic treatment.
Email
This form is collecting emails.Change settings
First name
First name
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Last name
Last name
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Cell phone
Cell phone
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Please describe if you are an osteopathic premed or medical student, at which school & in what year. If you are an osteopathic physician/practitioner, please describe where you currently practice & in what specialty.
Please describe if you are an osteopathic premed or medical student, at which school & in what year. If you are an osteopathic physician/practitioner, please describe where you currently practice & in what specialty.
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Please briefly describe how you heard about the clinic, and your interest in coming.
Please briefly describe how you heard about the clinic, and your interest in coming.
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Do you have a treatment table that you can bring?
Do you have a treatment table that you can bring?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Yes
No
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Do you plan to meet at Tomales Deli + Cafe at 5:15 pm for a group dinner before the clinic?
Do you plan to meet at Tomales Deli + Cafe at 5:15 pm for a group dinner before the clinic?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Yes
No
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Comments or additional info (allergies, disability services, etc.)
Comments or additional info (allergies, disability services, etc.)
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Link to Sheets
Summary
Question
Individual
Insights
Total points distribution
Loading...
Settings
Responses
Manage how responses are collected and protected
Presentation
Manage how the form and responses are presented
Defaults
Form defaults
Settings applied to this form and new forms
Question defaults
Settings applied to all new questions