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.

Question Title

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

Yes

Comments

Question Title

* 2. Name

First Name

Last Name

Question Title

* 3. Hospital

Question Title

* 4. Contact Information/Hospital Address

Name:

Hospital:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

Question Title

* 5. Can your hospital assist with patient transport expenses?

Yes

Uncertain

Please specify details of patient travel assistance available

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

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* 7. 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

Question Title

* 8. Hospital areas of specialization:

Question Title

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

Comments:

100% of survey complete.

Question Title

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

Question Title

* 2. Name

Question Title

* 3. Hospital

Question Title

* 4. Contact Information/Hospital Address

Question Title

* 5. Can your hospital assist with patient transport expenses?

Question Title

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

Question Title

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

Question Title

* 8. Hospital areas of specialization:

Question Title

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

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

Comments: