DHTML Menu, (c) 2004 Apycom Software FreeHIVinfo.com - Sponsored by Visionary Health Concepts offers free HIV & hepatitis treatment education materials - Organization Registration
 
   

 

 

 

 

 

Mailing List Registration for FreeHIVInfo.com

 

We are pleased to add you to our growing subscriber list for valuable, FREE education on the topic of HIV and hepatitis. Please answer the questions below about how you would like to receive this information, and then complete the registration form. 

 

Remember, some of the registration questions are optional, but will help us to continue to improve our knowledge-base of our readership, and better know the demographics of the clients you reach.  If you particularly like a program or are interested on a topic, please let us know in the “Comments” section below.

 

What brought you to our website today?

 

If other:

 

For fax/email programs (such as HepatitisWATCH),

please choose how you would like to receive the newsletter: 

 

For mailed programs, please select the quantity you

would prefer to receive (if available):

 

When available, please select quantity of Spanish-language

materials you would like to receive:

 

Please include me on all updates for NEW educational programs on hepatitis.

 

Please include me on all updates for NEW educational programs on HIV.

 

 

Tell us about your organization:                 

Please tell us a little about your organization, who you help and how we can assist you in better serving their educational needs.

 

First Name:*    Last Name:*   Degree:

Specialty:

Title:

 E-mail:*

 

Organization Name:*

Type of Organization

Address:*

 

Address 2:

City:*

 

State:*   

Zip Code:*   

Phone:

 

Ext:

Fax:

Web Address:

 

OPTIONAL:  The following information will help us better know our readers and their clients/organizations so we can provide quality and targeted education. Please take a moment to tell us about your clients/organization.

 

Population served

 

Approximate number of HIV and HCV clients served

 

Total HIV:

Total Consumers:    

Total HIV/HCV:

 

Total HCV:

 

Population demographics (by percentage)

African American:

%

Latino:

%

Asian/Pacific Islanders:

%

Caucasian:

%

Other:

Gay:

%

Women:

%

Transgender:

%

IVDU:

%

Substance Users:

%

 

What languages other than English or Spanish would you like to see?

 

Feedback

If you appreciate what you received from Visionary Health in the past, please give back a little time and energy to let us know which programs are your favorites and why. In addition, let us know what other educational topics you feel are important for you and your clients.

What other topics are you interested in?

 

 

What is your favorite Visionary Health program and why?

 

 

 

To view and download past programs, click here.

 

Privacy Statement: Visionary Health Concepts maintains databases for the sole purpose of distributing free HIV & Hepatitis treatment education materials. We don't sell or market any product; names in our database are never traded or sold. Any person listed in our databases will be immediately removed at their request. Mailed materials are always sent in confidential packaging.

 

 

 

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