First Name *
Last Name *
Email *
Organization
Title
Are you a health care provider? * Yes No
If yes; what type? * Physician (MD/DO) Physician Assistant Nurse Practitioner Registered Nurse Certified Nurse-Midwife Medical Assistant Other
If yes; where do you practice? * New York City only The Tri-State Area (NJ, NY, CT), which may or may not include New York City. Outside of the Tri-State Area (NJ, NY, CT)
If no; where are you located? * New York City only The Tri-State Area (NJ, NY, CT), not including New York City. Outside of the Tri-State Area (NJ, NY, CT)
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