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NH Bureau of Emergency Medical Service 33 Hazen Drive Concord, New Hampshire 03305 603-223-4200

FAX: 603-271-456 email: [email protected] web site: http://www.nh.gov/safety/divisions/fstems/ems/advlifesup/index.html

Clinical Practice Inquiry

Please submit to the NH Bureau of EMS, Advanced Life Support Coordinator,via regular mail, email, or fax. What is your question?

Please include background information that would be helpful to understanding the clinical significance of your question. You may mail, fax or email supplemental information to the Bureau office.

Submitted by: Name: Telephone: Email address: Facility Name: Mailing Address Date:

License Number:

Clinical Practice Inquiry Form updated May 26,2011

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