Mobile Health Clinic Request

BarnMD Mobile Health Clinic Request

Request a mobile clinic visit to your school, community, or organization in Nigeria

Full Name*

Email Address*

Phone Number*

Organization / Community Name*

State*

Local Government Area (LGA)*

Full Address for Clinic Visit*

Type of Requester*

Health Services Needed*

General Consultation

Maternal & Child Health

Vaccinations

Health Screenings (BP, Sugar, BMI, etc.)

Health Education Sessions

Mental Health Support

Other (describe below)

If “Other”, please describe:

Preferred Date(s)*

Expected Number of People Served*

Will your organization provide any of the following? (optional)

Venue

Volunteers

Refreshments

Publicity Support

Additional Notes or Comments

Date of Request*

We’ll contact you within 48 hours to confirm your request

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