Section 3: Accessibility and Availability (All fields required)

Public Transportation Access:*
TDD Capacity:*
If yes, please provide TDD Number:
Wheelchair Accessibility:*
Accepting New Patients:*
Completed by:*
Phone Number:*
Date:*


Section 4: Attestation (Required)

Attestation: I hereby certify that the information submitted within this survey is accurate and complete.*
Questions marked with an asterisk (*) are mandatory.