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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