Health Alert Notification Database (HAND)

Clinician Registration Form

The HAND is a confidential database used only to send out important and timely health information.

Please check to be sure information has been entered into the required fields, then click ‘Register’ below.

First Name		Last Name
Title	MD   DO   RN   NP   Other:
Phone (w/Area Code)		Fax (w/Area Code)
Organization		Department
Specialty		Subspecialty
Street Address
City	, CA	ZIP
Email Address
Pager		Cell Phone
Receive Health Alerts	via Fax   via Email
Working in	a Private Office   a Clinic	Name of Workplace
If in private practice, do you have another office? (if "Yes", please submit an additional registration)			Yes   No

Sometimes the Health Department sends out Health Alerts only to clinicians caring for certain type of patients.  For example, last year an outbreak of wound botulism occurred in injection drug users; rather than sending a Health Alert to all clincians, the Health Department sent the Alert only to clincians taking care of injection drug users.

Does your patient population include
Injection drug users	Yes   No	Homeless people	Yes   No
Homosexual clients	Yes   No	HIV-infected patients	Yes   No
Have you received Health Alerts in the past?	Yes   No	Were there any problems?	Yes   No
Are there other clinicians who work in your office or clinic?			Yes   No
	Register