Hospitals Accepting Non-funded Haitian Patients

If your institution can accept non-funded Haitian patients, please complete the following survey. You will be contacted regarding the initiative to transport patients as details become available.

Thank you.

1. Can your hospital accept non-funded Haitian patients in need of medical care? (If not, please disregard this survey. Thank you.)

Can your hospital accept non-funded Haitian patients in need of medical care? (If not, please disregard this survey. Thank you.) Yes

Comments

2. Name

Name First Name
Last Name

*
3. Hospital

Hospital

4. Contact Information/Hospital Address

Contact Information/Hospital Address Name:
Hospital:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

5. Can your hospital assist with patient transport expenses?

Can your hospital assist with patient transport expenses? Yes

Uncertain

Please specify details of patient travel assistance available

*
6. Please indicate the number of patients/beds allocated for non-funded patients from Haiti:

Please indicate the number of patients/beds allocated for non-funded patients from Haiti:

*
7. Can your hospital provide housing and sustenance to the Haitian parents/spouse/family member who accompanies the patient to the USA?

Can your hospital provide housing and sustenance to the Haitian parents/spouse/family member who accompanies the patient to the USA? Yes

Please specify details

8. Hospital areas of specialization:

Hospital areas of specialization:

9. Thank you for completing this survey, and for your humanitarian efforts.

Comments:

Thank you for completing this survey, and for your humanitarian efforts. Comments:

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