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* 1. Last Name

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* 2. First Name

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* 3. Please Indicate degree

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* 4. What organization or health center do you work for?

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* 5. Email Address

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* 6. Clinic Date

Date

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* 7. Clinic Title and Learning Objectives

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* 8. Please select the appropriate answer

  Yes No
Was this activity scientifically sound and free of commercial bias?
Was the program topic appropriate for your needs?
Did the program have practical clinical value?

T