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All fields are required unless otherwise noted.

First Name
Last Name
Name of Clinic/Practice/School
Medical License # or Tax ID #
Address 1		(no residential addresses, no P.O. boxes)
Address 2		(optional)
City
State
Zip
Phone Number
Fax Number		(optional)
E-Mail Address
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Please answer the following questions so we can better meet your needs:

What type of clinic best describes your office/facility?

Family / Group Practitioner
OBGYN
Urologist
College Health Care
High School Health Care
Family Planning Clinic
Public Planning Clinic
Other

What is your primary role?

Physician /Healthcare Practitioner
Manager
Administrator
Counselor
Teacher
Nurse
Other

On average, how many patients, students, or clients do you see per year?

Under 500
500-1,000
1,000-5,000
5,000-10,000
10,000+

On average, how many condoms do you distribute each month?

Under 500
500-1,000
1,000-5,000
5,000-10,000
10,000+
I do not distribute condoms

What are the ages of patients requesting information about safe sex from you? Select all that apply

Under 18
18-23
24-30
31-39
40+

From the choices below, which of the following provide the most value for your practice?

Education materials (brochures, posters, etc) provide the most value
Discounted condoms in bulk quantities provide the most value
Both are of equal value to my practice
Neither are of value to my practice

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