Medical Organization Survey

PLEASE COMPLETE ONE FORM FOR EACH PHYSICIAN/MEDICAL FACILITY

Community: *
Texas City Dickinson/Bacliff/San Leon Clear Lake League City Kemah/Webster/Seabrook Santa Fe LaMarque/Hitchcock Galveston Crystal Beach/Boliver
Volunteer Collecting Data:
Volunteer Name: * First Last
Volunteer Contact Phone: - ### - ### ####
Volunteer Email Address: *
Physician/Medical Facility Information
Medical Facility Name:
Physician Name: First Last
Speciality:
OB/GYN Pediatrician Family Practice Hospital Clinic
Street Address: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Mailing Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone - ### - ### ####
Contact Email:
Name of Office Manager: First Last
Does this office have a designated patient educator?
Yes No
If Yes who is your designated patient educator? First Last
Does this Physician/Clinic have posted hours?
(Please List Hours)
Does This Physician/Medical Facility:
(Please select all that apply)
Accept Medicaid Patients Participate In Community Outreach Events Conduct Patient Education Activities
Any other information we should know about this Physician/ Medical Facility as related to providing services to Pregnancy Center clients and their families?