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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.

 

Please tell us a little about you.      

You have chosen to register as an individual so please enter your personal contact information below. If you would also like to register your organization's information, follow the appropriate link after submitting this form.

 

First Name:*    Last Name:*  Degree:

Specialty:

Title:

Address:*

 

 Address 2:*

City:*

 

 State:*  

 Zip Code:*  

 Phone:

 E-mail:*

 

Demographic information (optional) - These questions are geared towards our HIV-positive, community visitors to better help us understand how we can better serve you.

Sex

 Female:  Male:

Age

 18-25      26-34     35-45     46-55     55+

Sexual Preference

 Straight:    Gay:     Transgender:    Other:

Race

African American:   Asian/Pacific Islander:  Caucasian:    Latino/Latina: 

 

Other:

I am interested in Spanish-language materials.

Please include me on all updates for NEW Visionary Health Concepts educational programs.

 What language would you like to see us produce educational material in:

 

        

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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