Register
Name
Mailing Address
Email
Phone
Age
Race/Ethnicity: Please choose all that apply.
Black/African-American
White
Hispanic/Latino
Asian
Native American/American Indian
Gender
Male
Female
Non-Binary/Other
Do you work for LG Health or another healthcare provider?
Yes, LG Health
Yes, another healthcare provider
No
Have you or an immediate family member ever been diagnosed with heart disease or diabetes?
Yes
No
Why are you interested in being part of this Community Advisory Board?
Do you have any dietary restrictions?