LOD Request for Information

Name

First Last

Organization

Department

Address

Street Address Address Line 2 City State ZIP Code

Email

Phone

Please select your areas of interest.

Activity hosting and Module Creation
Telehealth Training
Other (use notes section below to indicate needs)

Is your project for Healthcare Professionals or Patients?

Healthcare Professionals
Patients
Other (use notes section below to indicate needs)

Please give us a description of items you are interested in that were not listed above.

How did you hear about us?

Conference
Exhibit
Arkansas e-Link
UAMS Creative Services
Facebook
Referal (please list in notes section above)
Other (please list in notes section above)

Disclaimer

Completing this form does not guarantee services. The Center for Distance Health will consider projects and accept them depending on availability of resources as well as congruency with mission and current projects.

LOD Request for Information