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Doctor of the Month
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Nominate April's
Doctor of the Month
for
Tampa Bay

Is your doctor special?  Tell us how.
This is your chance to thank him or her.

Best stories will be posted.

If your nominee wins, you will receive dinner for two at a local popular restaurant.

Just complete the nomination form below.

April's winning doctor will be
announced to the press on May 1, 2007

Nomination Form

Please complete the contact information (in case you win) and describe specifically why your doctor should be Doctor of the Month.  100 to 500 words should do it.  To protect your confidentiality we will identify you by initials only on the site.  We will not share your contact information with any other party.  Monthly winners wil be chosen by the EQpractice staff.

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Comments:
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