First Name: MI: Last Name: Degree:
Which type(s) of Ryan White funding does your clinic receive? (select all that apply)
What is the estimated number of patients with HIV in care at your clinic?
How would you describe the community where you practice? (choose one)?
What issues would you like for the Coalition to address? (max. 1000 characters)
Your date of birth:
The Coalition is administered by HIVMA. For more information:
| IDSA | Contact Us
© Copyright HIVMA 2012 HIV Medicine Association