Medical Organization Survey
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
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State / Province / Region
Postal / Zip Code
United States
Country
Mailing Address:
Street Address
Address Line 2
City
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State / Province / Region
Postal / Zip Code
United States
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?