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LGBTQ Health Care Bill of Rights Request Form

Thank you for your interest in the LGBTQ Health Care Bill of Rights. Please fill out the information below to complete your request. A member of our team will contact you within two business days.
 
1. Are you a staff member at the NYC Department of Health? *This question is required.
2. Contact information
This question requires a valid email address.
3. Facility information
Services provided *This question is required.
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4. Contact information
This question requires a valid email address.
4. Facility information
Add another facility
4. Contact information
This question requires a valid email address.
4. Facility information
Add another facility
4. Contact information
This question requires a valid email address.
4. Facility information
Add another facility
4. Contact Information
This question requires a valid email address.
4. Facility information
4. I would like to receive information on how to be listed as an LGBTQ-knowledgeable provider in the NYC Health Map:
5. 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.
This question requires a valid number format.
7. Order refills
Please provide the quantity of the item(s) requested. Quantities shipped will depend on availability.
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