Please Fill Out the Form Below Name and Position of Primary Contact:(Required) Proposed Clinic Location Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work PhoneCell Phone(Required)Name of Organization To Host FreeD.O.M. Clinic USA:(Required) Email Address of Primary Contact(Required) Proposed Clinic Date(Required) Proposed Clinic Date Proposed Clinic Date What is your reason for hosting a free clinic?(Required)What type of services are you planning to have at your clinic? Dental Vision Medical What types of health care professionals do you have who can volunteer? Dentist Dental Assistant Dental Hygienist Optometrist Optician Ophthalmologist Medical Doctor PA/APRN Nurse Attorney Answering Phones Filing Paperwork Patient Registration General Office Please check all that applyWhat services or ministries to you currently offer to meet the needs of your community?What is your post clinic plan for follow up to continue to meet the needs of your community? *Marion County organizations - Hosting is FREE. Non-Marion County Organization/Host: There is a fee requirement of 50% to secure the available date and the remaining 50% due 1 month prior to the secured clinic date. Fees vary, please contact us for pricing. If you have other questions, feel free contact Ann Burnett, Executive Director, 352-421-5510 or [email protected].CommentsThis field is for validation purposes and should be left unchanged.
