Please take the time to give us a little information about yourself. We will have a drawing for a gift certificate to a local restaurant. One entry per household please. The winner will be notified by telephone and email. Enter by midnight September 30, 2001.The winner will be announced the 1st week in October

 

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
E-mail

Optional:

Are you a patient of Center for Primary Care? If so which office?

CPC Evans (Drs. Mobley, Fisher, Clark, Talley or Livingston)
CPC South (Drs. Scott, Barefield, Rassekh, or Harden)
CPC Central (Drs. Tomeo, Deshpande, D. Kennedy or P. Kennedy)

How did you find out about our web page?:

Newspaper
Flyer in office
Search Engine
Newsletter
Other

Would you like occasional email updates about items of interest from Center for Primary Care?

Yes

 

We respect your privacy and will NOT sell or give away your e-mail address at any time. Employees of Center for Primary Care and the immediate family or household members of CPC are not eligible to enter.