EmailMe Form - NAFC Volunteers in Medicine Program Contact Form

Name *

First Last

Clinic/Organization *

Email *

Phone *

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Proposed Clinic Location (City, State) *

How did you hear about the Volunteers in Medicine program? *

Describe your background and interest in starting a free clinic: *

Describe your community (rural/urban, demographics, major industries): *

Describe the perceived need for a free clinic (large number of uninsured individuals, emergency room overuse, etc.): *

Is there current community interest in starting a free/charitable clinic among churches, health care providers, hospitals, business community, etc.? *

Are you aware of any possible community resources for this project (retired medical professionals, funding resources, community support)? *

Have you started the planning for your clinic? If yes, please describe progress thus far. *

How can the NAFC Volunteers in Medicine Program assist you? *

Other comments?