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Please type responses here: |
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First Name:
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Last Name:
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Email Address:
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Retype Email Address:
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Phone Number:
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Institution:
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Title:
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Address:
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City:
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State:
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Country:
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Zip/Postal Code:
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My credentials (i.e., MD, RN, PhD, etc.) are:
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I practice/work in: (select all that apply)
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Emergency
Hospital
Urgent Care
Primary Care
Pharmacy
Specialized Clinic
Long-term Care/Nursing Home
Other Clinical Setting
Medical Distributor/Manufacturer/Supplier (if 'yes', you may skip the following question)
Non-clinical Setting
Other
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I specialize in: (select all that apply)
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Pediatrics
Family Medicine/Internal Medicine
Laboratory
Emergency Medicine
Urgent Care
Student/Resident
Administration
Pharmacy
Other area of clinical care
Operations/Practice Management
Other
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The HIV testing program at the facility where I work is best described as:
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My facility does not provide patient care
Established, part of routine care
Available, but not routine
Not in place; plan to implement
Not in place; no plans to implement, refer patients out
Do not know
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We currently screen all patients aged 13 – 64 for HIV.
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Yes
No
Not applicable
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By registering for this webinar, the information you provide will be shared with the webinar’s sponsor to provide you with information on products and services that may be of interest to you:
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Yes, I consent to receive marketing communication from this webinar’s sponsor following the webinar
No, thank you
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By registering for this webinar, Whitehat uses your information to communicate with you regarding this webinar and other educational events.
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After clicking 'submit', you
will be redirected to the webinar recording.
You will also
receive an email with the link to the evaluation to fill out
after you finish the recording. |
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