Health Care Provider/Professional Information Follow Up Form

Download and print this form to sign up health care providers or professionals who would like someone from FA to contact them with more information.

If you want someone from FA to contact you about this organization in the future or wish additional literature and information, please complete the form below and someone will contact you.

Name of Professional or Group _________________________________________

Street Address _________________________________________

City _________________________________________

State _________________________________________

Zip _________________________________________

Telephone _________________________________________

Email address _________________________________________

I am interested in the following:

ï‚‘ FA Information meeting for patients/clients

ï‚‘ Additional FA pamphlets for patients/clients

ï‚‘ Rack of FA pamphlets to display in my waiting room or office

ï‚‘ Panel information session for staff

ï‚‘ Slide presentation for staff

ï‚‘ Local contacts for patients/clients

ï‚‘ Complementary copy of the book Food Addicts in Recovery Anonymous ï‚‘ Posting FA weblink on my resource page

ï‚‘ Other: