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2. Do you live or work in Snohomish County?

   1. Yes
   2. No
3. The list you are signing up for provides alerts specifically for Snohomish County. If you do not live or work in the county, you still may sign up for alerts, but should be aware that they may not apply to the county in which you are located.

   1. I understand
5. First Name
6. Last Name
8. Email
9. Phone number (text notifications)
10. Phone number (call)
12. What type of provider or practice are you associated with?
    -- Select One --MedicalDentalVeterinaryPharmacy
13. What is the name of the clinic, pharmacy or practice?
14. Clinic/business phone number
    We may call to verify your employment with a medical, dental, pharmacy or veterinary practice. This list is specifically for providers and their teams.
16. In what city is the clinic, pharmacy or practice located?
    If you are located in unincorporated Snohomish County, please identify the city or town closest to you.
17. What is your role?
    -- Select One --Provider (doctor, veterinarian, dentist, or pharmacist)Nurse (or veterinary technician)Clinical Support StaffOffice ManagerOffice Support StaffOther
18. If you selected "Other," please specify your role
20. Specialty (if applicable)
21. Credentials (if applicable)
    MD, DVM, PharmD, DDS, RN, ARNP, etc.
22. Would you also like to subscribe to non-emergency messages from our Health Officer, such as notifications of continuing education, upcoming events, etc.

    1. Yes
    2. No
24. Additional Information (optional)
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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