REFERRAL FORM
Quality Health Clinic would like to expand its Information, Education and Communication services to others people as well as legal entities and establish constructive partnerships. Kindly use this form to recommend a legal entity; this can be a school, a church, an association, a company and so forth. Your assistance will be highly appreciated.
Kindly select the topic for which you are making a referral.
I. INFORMATION OF THE PERSON WHO MAKES A REFERRAL
NOTE
Kindly skip this section if you prefer to remain anonymous.
Thank you for your referral.