Diabetes Service Organization Addition

Please complete this form below. Then click the submit button at the bottom of the page to enter the information into VCCC Diabetes Services Directory.

*  Required fields
Organization Name:*
Address:*
Address Line 2:
City:*
State:*
Zip:*
Phone:* Format: 123-456-7890
Fax: Format: 1234567890
E-Mail:* Format: name@domain.com
Website: Format: http://www.valleyccc.org
Other Locations :
Contact Person - Name:*
Contact Person - Phone:* Format: 123-456-7890
Contact Person - Email:* Format: name@domain.com
Services Provided: Primary Medical Services
Specialty Medical Care - Type:
Educational Classes - Types:
Support Groups
Screenings
Counseling
Nutritional Support
Diabetic Supplies
Exercise Classes
Low Cost Pharmacy
Other - Details:
Area/Communities Served:
Hours/Days of Operation:
Do they serve people without insurance? Yes - Criteria:
No
Languages Spoken:
Are any services provided for free? Yes - What Services?
No
Are services coordinated with other agencies? Yes - Who?
No
Are your currently accepting new clients? Yes
No
What are the capacity limitations ? Space
Funding
Other - Details:
Additional comments/notes
Submitter Name:*
Submitter Email:*
Submitter Phone:*

 

 
 
7515 Van Nuys Blvd., 5th Floor Administration - Van Nuys, CA 91405
Tel: 818.947.4026 or 818-947-4040 Fax: 818-989-8850