Hospital Nomination
Nominate a hospital that you believe qualifies for free medical software, DynaMed Plus
Email address *
What is your first name? *
What is your last name? *
What is your email address? *
Have you received PEMSoft or DynaMed Plus from KidsCareEverywhere in the past> *
What is the name of the hospital you are nominating? *
What COUTRY is this hospital or medical school in? *
What CITY is this hospital or medical school in? *
How many physicians, residents, and/or medical students are there at this hospital or medical school? *
What level of English proficiency do the physicians at this hospital/medical school have? *
This question is important so that we can translate our training materials if necessary
What type of mobile phone do most people use at this hospital? *
Does this hospital have access to Up-To-Date *
What is your relationship to this hospital or medical school? *
Please provide the contact information for the head of the hospital or medical school being nominated
Please provide their full name, title and email address. This information is needed so that we may contact them for further coordination and organization of a trip.
Submit
Never submit passwords through Google Forms.
This form was created inside of KidsCareEverywhere. Report Abuse