Join us for a FREE Hepatitis Testing & Education Event – Tues May 19, 2015

FREE Hepatitis C Testing & Education Event

Tuesday, May 19th from 10am – 2pm

Join us for free Hepatitis testing, lunch, and educational sessions. Lunch & Learn will be held from 12-1pm. Registration is REQUIRED.

To register, please fill out the attached form, indicating your preferred testing time frame and return to social@absolutecarehealth.com or Freda Jones @ AbsoluteCARE 404.231.4431.

You will receive a confirmation of your time slot prior to the event. We look forward to seeing you! □ 10:00-10:15am □ 10:45-11:00am □ 11:30-11:45am □ 1:15–1:30pm □ 10:15–10:30am □ 11:00–11:15am □ 11:45am-12:00pm □ 1:30-1:45pm □ 10:30-10:45am □ 11:15a–11:30am □ 1:00-1:15pm □ 1:45-2:00pm

Demographics:
_______
Name Phone Number
E-mail Address
City of Residence Zip Code County of Residence
Birth date: / / Age:
Gender: □ Male □ Female □ Transgender (MTF) □ Transgender (FTM)
Ethnicity (mark only one): Race (mark all that apply):
□ Hispanic or Latino □ Asian
□ Non- Hispanic or Latino □ Black or African American
□ Decline to Answer □ Native American or Alaskan Native
□ Native Hawaiian or Pacific Islander
□ White
□ Other __________________
□ Decline to Answer

Rapid HCV Testing Form 5.19.15 Event

Join us for a FREE Hepatitis Testing & Education Event – Tues May 19, 2015

Free Hepatitis C Testing and Education Event

FREE Hepatitis C Testing & Education Event

Tuesday, May 19th from 10am – 2pm

Join us for free Hepatitis testing, lunch, and educational sessions. Lunch & Learn will be held from 12-1pm. Registration is REQUIRED.

To register, please fill out the attached form, indicating your preferred testing time frame and return to social@absolutecarehealth.com or Freda Jones @ AbsoluteCARE 404.231.4431.

You will receive a confirmation of your time slot prior to the event. We look forward to seeing you! □ 10:00-10:15am □ 10:45-11:00am □ 11:30-11:45am □ 1:15–1:30pm □ 10:15–10:30am □ 11:00–11:15am □ 11:45am-12:00pm □ 1:30-1:45pm □ 10:30-10:45am □ 11:15a–11:30am □ 1:00-1:15pm □ 1:45-2:00pm

Demographics:
_______
Name Phone Number
E-mail Address
City of Residence Zip Code County of Residence
Birth date: / / Age:
Gender: □ Male □ Female □ Transgender (MTF) □ Transgender (FTM)
Ethnicity (mark only one): Race (mark all that apply):
□ Hispanic or Latino □ Asian
□ Non- Hispanic or Latino □ Black or African American
□ Decline to Answer □ Native American or Alaskan Native
□ Native Hawaiian or Pacific Islander
□ White
□ Other __________________
□ Decline to Answer

Rapid HCV Testing Form 5.19.15 Event

Free Hepatitis C Testing and Education Event