аЯрЁБс>ўџ 79ўџџџ6џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅСM љПdbjbjт=т= " €W€WdџџџџџџlPPPPPPPœ4œtT єєєєє"* ѓѕѕѕѕѕѕ$’ ВфP6єє66$ PPєє.$ $ $ 6ЪPєPєѓ$ 6ѓ$ $ .ЇPPѓєH № IТЦœ|ФПѓD0tЧ,–Ф`–ѓ$ d „PPPPй D.O. and Osteopathic Medicine Patient Testimonial Form Because your physician is a D.O., you have become familiar with osteopathic medicine. However, a large portion of the American public does not know about D.O.s and that they are fully-licensed physicians. If you have overcome struggles or beat the odds with the help of your D.O., let us know. Through your story/testimonial, the INSERT ASSOCIATION NAME can educate the public about the osteopathic medical profession. The (INSERT ASSOCIATION ACRONYM) will share your story with specific media outlets (i.e. newspapers, magazines, Web sites, or television) so there is the possibility that journalists will want to interview you. If you would like the INSERT ASSOCIATION ACRONYM to consider using your testimonial for its public education efforts, please take a few minutes to answer the questions listed below. If you need additional space, attach separate sheets of paper. In general, what were the circumstances and how did your D.O. help you? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ When it comes to the medical care your D.O. provided, what stands out (i.e. amount of time spent with you, quality of care, etc.)? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Are you familiar with osteopathic manipulative treatment (OMT)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Did your D.O. use OMT to treat you?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Is the D.O. your primary care physician?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Who is your D.O.? Please provide us with the D.O.’s contact information (name, address, phone number, and fax number). _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Would you be comfortable speaking to the media about your experience with osteopathic medicine?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If you answered yes to the above questions, please indicate which media you prefer. Select all that apply.  FORMCHECKBOX  Newspapers  FORMCHECKBOX  Magazines  FORMCHECKBOX  Radio  FORMCHECKBOX  Television  FORMCHECKBOX  Web sites Please provide your contact information. ________________________________________________________ Name ________________________________________________________ Address _________________________________________ City, State, and ZIP code _________________________________________ Phone _________________________________________ Fax _________________________________________ E-mail Please mail the completed form to: ASSOCIATION NAME CONTACT NAME ADDRESS CITY, STATE ZIP The form can also be sent via fax at INSERT FAX NUMBER or by e-mail to INSERT E-MAIL ADDRESS. If you have questions, please contact CONTACT NAME at PHONE NUMBER. 9:eЖЭч     # $ 2 3 4 \ ] k l m r s  ‚ ƒ А Б П Р С Ц Ч е ж з ЗИЦљђљщнщнщащРащащАащащ ащащащащ€ащащpащащjDCJOJQJU^JjаCJOJQJU^Jj\CJOJQJU^JjшCJOJQJU^JjtCJOJQJU^JjCJOJQJU^JjCJOJQJU^J5CJOJQJ\^JCJOJQJ^J OJQJ^J OJQJ^J(9:  ЖЗ­Ўі  # Э 8 ‡ л S STЖЗуфPQ§§§ћћћћћћћїїїїюююїїїћћћшћћ„h^„h ЦшˆЄ№Є№d§ЦЧШЮЯнопQR`abst‚ƒ„‘’ ЁЂЊЋЙКЛШЩзийeОхіEQUaятйтйЩтйтйЙтйтйЉтйтй™тйтй‰тйтйyтйmйmйmйmйm5CJOJQJ\^JjpCJOJQJU^JjќCJOJQJU^JjˆCJOJQJU^JjCJOJQJU^Jj CJOJQJU^Jj,CJOJQJU^JCJOJQJ^JjCJOJQJU^JjИCJOJQJU^J*QфхцIN‡Йг§-1[bcde‰šЇПРdјіёёёёёёёёёёёёёёёёёёёяяяёё$a$ Ц TacdїюCJOJQJ^JCJOJQJ^J 1hАа/ Ар=!А "А # $€%АtDџџџџeCheck1tDџџџџeCheck1tDџџџџeCheck1tDџџџџeCheck1tDџџџџeCheck1tDџџџџeCheck1tDџџџџeCheck1tDџџџџeCheck1tDџџџџeCheck2tDџџџџeCheck2tDџџџџeCheck2tDџџџџeCheck2tDџџџџeCheck2 i8@ёџ8 NormalCJ_HaJmH sH tH <A@ђџЁ< Default Paragraph FontFC@ђF Body Text Indent$„h^„ha$CJ.>@. Title$a$ 5CJ\.U@Ђ. 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