Request Form -

Please fill out this form and click submit

1. Contact information

First name *This question is required.

Last name *This question is required.

Office title *This question is required.

Organization name *This question is required.

Street address *This question is required.

Suite/Office

City *This question is required.

State *This question is required.

ZIP code *This question is required.

Email address *This question is required. This question requires a valid email address.

Phone number *This question is required.

Organization's website

2. Facility information

Other *This question is required.

Add another facility

3. Contact information

Organization name *This question is required.

Street address *This question is required.

Suite/Office

City *This question is required.

State *This question is required.

ZIP code *This question is required.

Email address *This question is required. This question requires a valid email address.

Phone number *This question is required.

Organization's website

3. Facility information

Other *This question is required.

Add another facility

3. Contact information

Organization name *This question is required.

Street address *This question is required.

Suite/Office

City *This question is required.

State *This question is required.

ZIP code *This question is required.

Email address *This question is required. This question requires a valid email address.

Phone number *This question is required.

Organization's website

3. Facility information

Other *This question is required.

Add another facility

3. Contact information

Organization name *This question is required.

Street address *This question is required.

Suite/Office

City *This question is required.

State *This question is required.

ZIP code *This question is required.

Email address *This question is required. This question requires a valid email address.

Phone number *This question is required.

Organization's website

3. Facility information

Other *This question is required.

Add another facility

3. Contact Information

Organization name *This question is required.

Street address *This question is required.

Suite/Office

City *This question is required.

State *This question is required.

ZIP code *This question is required.

Email address *This question is required. This question requires a valid email address.

Phone number *This question is required.

Organization's website

3. Facility information

Other *This question is required.

3. I would like to receive information on how to be listed as an LGBTQ-knowledgeable provider in the NYC Health Map :

4. I would like to request a LGBTQ Health Care Bill of Rights:
*Note: Let us know how many additional languages you need by clicking the respective boxes below.

Starter kit (60 wallet cards (English and Spanish), 2 posters, 1 tabletop easel in English and Spanish)
Russian wallet cards (15)
Haitian Creole wallet cards (15)
Korean wallet cards (15)
Chinese wallet cards (15)
French wallet cards (15)
Arabic wallet cards (15)
Refill

5. Please provide the quantity of starter kits requested (one kit per facility) This question requires a valid number format.

6. Order refills

Please provide the quantity of the item(s) requested. Quantities shipped will depend on availability.

Wallet card - English (15 cards per refill)
Wallet card - Spanish (15 cards per refill)
Wallet card - French (15 cards per refill)
Wallet card - Haitian Creole (15 cards per refill)
Wallet card - Chinese (15 cards per refill)
Wallet card - Russian (15 cards per refill)
Wallet card - Korean (15 cards per refill)
Wallet card - Arabic (15 cards per refill)
Tabletop easel
Poster - English
Poster - Spanish