County of Santa Clara Public Health Department Health Officer

First Name *

Middle Name

Last Name *

Office Address

Street Address Address Line 2 City State/Prov/Region Postal/Zip Country

Office Phone Number

Cell Phone Number

Office Fax Number

Email Address *

Provider Type *

Select your Provider Type here. If you select 'Medical Provider' please choose a Specialty in the drop down.

Provider Type - Write In

Primary Speciality *

If you selected 'Medical Provider' above, please select a Speciality.

Primary Speciality - Write-in

Facility Type *

Select your 'Facility Type' here. If 'Clinic' is selected, please select 'Clinic' below. If 'Hospital' is selected, please select 'Hospital' below.

Facility Type - Write-in

Facility Name