Donor Form

As a no-cost service to patients, we need your help.

The COVID-19 pandemic threatens all of us. Even those lucky enough to avoid physical health tolls are faced with difficult economic realities that have already begun to take effect.

We are asking that any organization or individual in a position to help might consider making a donation. This will allow us to rapidly add capacity for everything ranging from compute infrastructure to supporting, coordinating and expanding our network of volunteer physicians and nurse practitioners around the country.

After you submit the form, one of our team members will be in touch to follow up. We thank you in advance for anything you may be able to do.

We are working around the clock to launch this initiative and will be posting more public-facing content in the coming days at

Please Note:
-- If you are a licensed healthcare worker and looking to help see patients through our Virtual Field Clinic, please visit this form:

-- We are currently accepting registration for non-healthcare workers to volunteer as well. Learn more here:
Email address *
First Name *
Your answer
Last Name *
Your answer
Mobile Number *
Your answer
Web Link
A link to your site, portfolio, online resume or LinkedIn profile - if you would like to share.
Your answer
About you
Anything else you'd like to share about yourself.
Your answer
Donation Type
Monetary Contribution
For monetary contributions, please let us know the approximate level of contribution you are able to consider. Any and all contributions matter and are sincerely appreciated. In this great time of national and global need, we are looking to our more fortunate fellow humans to help us make the largest impact possible
In-Kind Contribution
Money isn't everything. If you have another way you feel you can help make an impact, such as donations of corporate staff time, or infrastructure please let us know what you may be in a position to offer.
Never submit passwords through Google Forms.
This form was created inside of liveclinic. Report Abuse