Mobile Clinic - Partnership Questionnaire

Mobile Clinic Partnership Questionnaire Form

Black Hawk County Public Health (BHCPH) seeks to improve access to essential health services across urban and rural communities. Through partnerships we can make an even bigger impact on the health of the community. If your organization would like to explore a partnership with BHCPH Mobile Health Clinic Services, complete and return the questionnaire linked below. Our Clinical Services Manager will contact you within seven to ten business days to schedule a date and time to discuss collaboration opportunities.

1. Contact Name/Title

2. Address (City, State, Zip)

3. Phone Number

4. Email Address This question requires a valid email address.

5. Organization Name

6. Description/Type of Organization

7. Provide a brief description of collaboration idea(s)