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Dudley P.C. LLC
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Intake form
Help us serve you better
Name
*
Email address
*
What services are you interested in?
Please select at least one option.
Wellness Program Consultations
Health Literacy Programs
Preventive Care Workshops
Community Health Assessments
Other Health Related Assessments/Programs
What is your primary goal?
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Improve Health Literacy
Increase Access to Wellness Programs
Enhance Preventive Care
Build Community Partnerships
Alternative Goals
How did you hear about us?
*
Please select at least one option.
Social Media
Referral
Online Search
Community Event
What is your preferred method of communication?
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Email
Phone
Video Conference Call
What is your organization type?
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Select
Government
Nonprofit
Corporate
Small Business
Educational Institution
Healthcare Provider
What is your target audience?
*
Please select at least one option.
Adults
Children
Seniors
Low-Income Communities
Individuals with Chronic Illness
New Parents
Do you have a specific timeline for your project?
Additional service questions or comments
Which service or services are you interested in?
Please select at least one option.
Small Businesses
Commercial Businesses
Organizations and Governments
Select a preferred date and time to meet
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Select a date and time
September
2018
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