CLINIC ATTENDANCE REQUEST FORM for Health Professionals
Hello Physician or Health Professional!

Our next trip will be taking place on May 20, at our Ensenada clinic site in Mexico.

We will meet for the trip at 5:30 AM, in the parking lot in front of Stein Clinical Research on the School of Medicine Campus (Search "lot P602" or "Stein Clinical" at maplink.ucsd.edu). We will arrive back at UCSD around 7-10 PM, depending on how long it takes to cross the border, so please plan accordingly.

Remember that you MUST have a valid US passport, green card, or passport card in order to attend.

Please feel free to contact us with any questions, comments, or concerns regarding the upcoming clinic trip at
ucsdflyingsams.pro.recruiter@gmail.com

Looking forward to a great clinic!

Health Professionals Correspondent
of Flying Samaritans UCSD
ucsdflyingsams.pro.recruiter@gmail.com

Clinic Coordinators
of Flying Samaritans at UCSD
ucsdflyingsams.cliniccoord@gmail.com

web ucsdflyingsams.com
email fs.ucsd@gmail.com

First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Email *
Your answer
What documentation will you be bringing to attend this trip? *
Required
What type of provider are you? *
If you selected "Other" above, please specify:
Your answer
What is your level of Spanish fluency?
Will you be meeting us at Stein Clinical Research (UCSD Campus) on the morning of the trip, or meeting us at the clinic in Mexico?
Your answer
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