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GHG Scholarship Program

Find a Physician Form

Name:*
Address:*
Your Phone Number:*
What kind of physician are you looking for?:
What specific preferences do
you have for your physician?
 Male
 Female
 Younger
 Experienced
 Will Use a Nurse Practitioner
 Do Not Want to Use a Nurse Practitioner
Geographic Location Preference:
Accessibility Requirements? Some of our offices you can park right outside the door, others require a walk to a common building. Do you have a preference? Tell us about any physical limitations for access.
My main concern that I would like to see treated is:
Check all conditions that you currently need help to manage. Check all that apply:
 Diabetes  Blood Pressure
 Arthritis  Cancer Diagnosis
 Heart Disease Diagnosis
For payment I will be using:
As the patient, you are responsible for verifcation of participating providers allowed on your panel.
Best time to contact back with questions or suggestions between the hours of 8-5 Monday-Friday?
Please type the code shown in the image: