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General Information

First Name:    MI:    Last Name:    Degree:  

Clinic Information

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)

Optional Demographic Information

Your race/ethnicity: 

Your gender:

Your date of birth:

 (mm/dd/yyyy)