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Teen Clinic - Expression of Interest
Thank you for your interest in Teen Clinic.
To assist us in getting to know your practice please complete the following questions.
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Email
*
Your email
Name of the contact person
*
Your answer
Your Practice
Name of practice
*
Your answer
Location
*
Your answer
How many GP’s in your practice?
*
Your answer
How many Registered Nurses?
*
Your answer
Have you discussed the Teen Clinic model with others in your practice?
*
Reception
GP’s
Nurses
Practice manager
No I haven't discussed it with others at this stage
Other:
Required
Please let us know why you would like to implement Teen Clinic in your practice?
*
Your answer
Your Community
Please provide us with some information about your community.
*
What is the community need, issue or gap that Teen Clinic will help to address?
Your answer
Any other information you would like to share?
Your answer
A copy of your responses will be emailed to the address you provided.
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