Hello! Thanks for taking the time to answer some questions for NotesFirst! We are collecting this information to choose a select few medical mission doctors to receive a complete NotesFirst platform package (eg. 2 iPad minis and a 1 year subscription to the NotesFirst application) to take with you on your journey.

Name

First Name

Last Name

Email Address

Name of your medical mission program or organization:

Target destination(s) for 2015 and 2016?

What type of facilities are you targeting?

For example: hospital, orphanage, government facility.

How many total physicians/medical providers are traveling?

What is the estimated number of patients you are expecting to treat?

Will you have internet access during your trip?

For example: cellular network, Wifi, etc.

During your trip, will you be working with local medical providers?

Will you be working with the local medical providers for follow-up care, or plan for a follow-up trip to the location?

Will you be working with any local/national government or educational institutions in your target location?

Are you currently involved in global health research?

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