Clinic Modification Form

Thank you for helping us keep our map up to date! Please complete the form below to request edits to your listing(s) on the FWGBD Service Map Directory.

Centers and their affiliated clinics should be considered separate listings (i.e., an HTC and its Women & Girls Clinic, or a Bleeding and Clotting Center and its Women’s Clinic). Affiliations can be noted on the second page of this form, after service selection. Therefore, you may need to submit this form multiple times if you have separate clinics from your center, which should be included.

Service Selection:
Please select all that you provide, not only new. By completing this form, we will update all offerings to reflect only what is checked at the time of this update.

FWGBD Clinic Directory Modification Form

FWGBD Clinic Directory Request
Request Type

For additional questions or interest in the WGBD® Clinic of Excellence program, please contact Kerry Funkhouser, EdD, FWGBD Executive Director at kfunkhouser@fwgbd.org.