KaviKrishna Telemedicine Care

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Community Health Camps Request

Community Health Camp Request Form

Personal Information

Organization Name *

Representative Name *

Contact Number *

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Secondary Contact Number

Address

Street *

City/Town *

State *

Pincode *

Proposed Health Camp Information

Type of Health Camp Requested (Check all that apply) *

General Health Check-Up

Blood Pressure & Sugar Check

Cancer Screening

Women’s Health (Breast Cancer, Cervical Cancer Screening)

Other

Preferred Start Date *

Preferred End Date *

Preferred Time *

Morning (9:00 AM – 12:00 PM)

Afternoon (12:00 PM – 3:00 PM)

Evening (3:00 PM – 6:00 PM)

Expected Number of Participants *

Less than 50

50 – 100

100 – 200

More than 200

Healthcare Needs of the Community

Describe the main health concerns in your community

Are there any ongoing health issues that need special attention? *

Yes

Facilities Available for the Camp

Is there an appropriate space available for setting up the camp? *

Yes

Description of the space available

Does the location have access to clean water and sanitation? *

Yes

Is there electrical power available? *

Yes

Logistics & Support

Is the community able to provide volunteers to assist during the camp? *

Yes

Number of volunteers you can provide

Can the community assist with transportation for medical staff or equipment? *

Yes

Digital Signature

Representative Name *

Signature *

Date of Signature *

Additional Comments or Special Requests

We, the undersigned, request a health camp for our community and are willing to assist in making the necessary arrangements for its smooth conduct.

* required

0361-283 0009

[email protected]

KaviKrishna Telemedicine Care, College road, Kanchan Nagar Rd, Kanchan Nagar, Sualkuchi, Assam 781103, India

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