Gift of Health Recipient Application Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Email Address Question Title * 4. Primary Phone Number Question Title * 5. Clinic/Practice Name Question Title * 6. Clinic/practice State Question Title * 7. Clinic/Practice City Question Title * 8. Is your Clinic/Practice a non-profit organization? Yes No Question Title * 9. What percentage of your patient base receives care at a reduced or free rate? 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 10. Please explain how your clinic serves those in need. Question Title * 11. Please describe how the free food sensitivity tests would be used within your practice/clinic. Question Title * 12. Is there anything else you would like us to know or to take into consideration? Question Title * 13. Clinic/Practice Website URL Done