WICOMICO COUNTY HEALTH DEPARTMENT

Physician Notification Registration Form

The Wicomico County Health Department is currently providing weekly community updates. These updates are posted regularly on the health department website. We would like to provide H1N1 updates and other agency news releases that would be important to your patients directly to your office in a format that is convenient to you. Please take a moment to complete the response information below so that we will be able to get information to you in the most efficient way.

 

If you would like to receive notifications via email, please complete the registration form below and your name will be added to our email distribution list.

You may also click here to download and print the form and fax it to Tammy Griffin at (410) 548-5184. (Do not complete the registration below if you will be faxing your form.)

 

If  you have any questions, please contact Tammy Griffin, agency Public Information Officer at (410) 334-3480, or via email: griffintl@dhmh.state.md.us

 
Name of Practice:
 
Doctors in Practice:
 
Mailing Address: 
Street Name:
City:               
State:            
Zip:              
 
Office Phone:        
 
Office Fax:            
 
Office Manager:   
 
Email Address(es) to receive notifications: