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GPCO 5th Annual Health-Fair & Back-2-School Provider Registration Form
Date:
July 22nd, 2023
Setup Time:
8:30
-
9:30am
Address:
Alamo Colleges District.
Westside Education and Training Center (WETC)
610 SW 41st Street, San
Antonio
TX 78237.
Contact: (210)-914-7284 or
bunmi.a@gracepavilion.org
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* Indicates required question
Email
*
Your email
Name of Provider/Organization
*
Your answer
Indicate Care Specialty.
*
Primary Care/ Internal Medicine
Pediatrician
Mental Health
Dental
Vision
Other:
Required
Contact Person
*
Your answer
Contact Phone Number
*
Your answer
Name(s) of providers or nurses participating (If more than one, kindly separate with a comma).
*
Your answer
Select discipline as applicable to your care team:
*
Physicians/Mid-Level Providers
Nurse
Medical Students
Physical/ Occupational Therapists
Nutritionist
Dentists
Optometrist
Respiratory Therapist
Other:
Required
Total Number of Participating Team Members (If applicable)
*
Your answer
Which of the following are you offering?
*
Health Screening
Consult (Providers Only)
Health Screening & Consult (Providers Only)
If you are offering health screening, kindly indicate the type of screening.
*
Weight Management
Diabetes Screening
Blood Pressure Check
Dental Screening
Vision Screening
Other:
Required
Are you donating any school supplies? (Branded & non-branded items are acceptable)
*
Yes
No
If yes, kindly list the items you will be donating.
*
Your answer
We will provide a table and two chairs, please indicate if you have any other special setup needs.
*
Your answer
A copy of your responses will be emailed to the address you provided.
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