C-UPHD Car Seat Appointment

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* 1. What is your First and Last name?

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* 2. What is your address?

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* 3. City and Zip Code

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* 4. What is your email address?

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* 5. What is your telephone number?

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* 6. What kind of car seat do you need checked? (select all that apply)

I am having a baby and need my infant rear-facing seat checked.

I have an infant or toddler and need my convertible seat checked.

I have a toddler and need my forward-facing seat checked.

I have a child and need my booster seat checked.

I am on W.I.C. and need a car seat.

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* 7. My Due Date or Child(ren) information(name, age, weight) is...

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* 8. How did you hear about us?

WIC/ CUPHD

Law Enforcement

Fire Department

School District

Hospital

Other (please specify)

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* 9. What time works better for you to come in?

9:00 or 9:30

10:00 or 10:30

11:00 or 11:30

12:00 or 12:30

1:00 or 1:30

2:00 or 2:30

3:00

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* 10. What concerns do you have about car seat use and installation?

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* 11. What is your preferred method of communication?

Phone

Mail

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* 1. What is your First and Last name?

Question Title

* 2. What is your address?

Question Title

* 3. City and Zip Code

Question Title

* 4. What is your email address?

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* 5. What is your telephone number?

Question Title

* 6. What kind of car seat do you need checked? (select all that apply)

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* 7. My Due Date or Child(ren) information(name, age, weight) is...

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* 8. How did you hear about us?

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* 9. What time works better for you to come in?

Question Title

* 10. What concerns do you have about car seat use and installation?

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* 11. What is your preferred method of communication?

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* 12. Do you have any other questions, comments, or concerns?