Please share your thoughts and plans on starting a new faith-based medical/dental clinic.

Contact Information

First Name

Last Name

Phone Number

Address

Address Line 1

Address Line 2

City

Zip/Postal Code

State

Name of Church or Lead Organization:

Name of Clinic (if known):

What is your vision for your clinic? (i.e. What population to do expect to serve, services you plan to offer, frequency of operation etc.)

Where are you in the development process? Please describe your progress to date.

Describe your leadership team.

Have you identified a lead physician?

How many doctors, nurses, and other health professionals have expressed an interest in your project?

Have you identify financial resources to support your project?

What type of support do you need? (It's ok to say "I don't know")

How did you hear about CCHF?