Healthcare Provider Outreach
North Shore Intergroup is preparing to send OA information to health care professionals and therapists in our area. Please help with our professional outreach mailing by providing the addresses of health care professionals, therapists, nurse practitioners, dieticians, nutritionists, dentists, etc. with whom you may be in contact. Just fill in the information below and NSI will take care of the rest.
Healthcare Provider's Name *
Your answer
Company Name
Is there a name for the practice, hospital, etc?
Your answer
Street Address *
Your answer
City *
Your answer
State *
Provider's Phone Number
Your answer
Comments
Is there anything that we should know, when we contact this provider? If you do NOT want to send this packet anonymously, you may also leave a note for the provider in this space.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service