3M Collective: Medical Professional Volunteer Applicants

3M Collective

Medical Mission Match Volunteer Registration Form
Medical Volunteer Information
Name (Enter as on Passport)

First NameMiddle NameLast Name(e.g. MD)
Email
Enter your email
Mobile Number | WhatsApp | Telegram | Signal

Country CodeArea CodePhone Number
Your NPI Number (For US Medical Professionals): https://npidb.org/npi-lookup/
To lookup your NPI: https://npidb.org/npi-lookup/
Which hospital or health system do you currently have priveleges?
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Date of Birth

MonthDayYear
Only needed if you plan to fly internationally.
Languages fluently spoken in addition to English
Country of Citizenship (Primary)
Only needed if you plan to fly internationally. Passport must not expire within 6 months of travel.
Country of Citizenship (Secondary)
Only needed if you have multiple citizenship. Passport must not expire within 6 months of travel.
Emergency contact person

First NameLast Name
Emergency Contact Mobile Number

Country CodeArea CodePhone Number
Signup for one 4hr Saturday TeleConsult CallShift

Can you cover at least one 4hr TeleConsult call shift on a Saturday? During this 4hr period, general practitioners may need specialist consultation support (e.g. Dermatology, Infectious Disease, etc.). All you need is a phone and the ability to speak English. 4hrs/year.
Select your Clinical Specialty to Cover a TeleConsult Call Shift?
Type of Healthcare Provider
Pick one Saturday Shift where you can cover from 9:00am-1:00pm EST (New York, US Time)

MonthDayYear
Pick one date. The availability shift is 9am-1pm EST.
Dates of Travel | International Medical Mission Work

Minimum Duration. 2 Weeks.
Select Your Specialty | ****On Site Medical Missions Volunteer Work****
For Surgical Medical Mission Trips
How many continuous weeks can you commit to the international medical mission trip (minimum is 2 weeks)?

Other
1st Choice Start Date for 10-14 Day Medical Mission

MonthDayYear
Select your desired Start Date for a 10-14 Day onsite Medical Mission
2nd Choice Start Date for 10-14 Day Medical Mission

MonthDayYear
Select your desired Start Date for a 10-14 Day onsite Medical Mission
3rd Choice Start Date for 10-14 Day Medical Mission

MonthDayYear
Select your desired Start Date for a 10-14 Day onsite Medical Mission
What is the least amount of advanced notice you need prior to going on an international mission trip (In Weeks)?
Are you able to work in an unstable or low resource environment?
How many hours of medical mission work experience do you have?
What type of patient care experience do you have?

Other
Workload Tolerance
Please indicate highest number of hours you are able to work in a day
Other Information
Who referred you to the 3M Collective?

Other
Should be Empty:

3M Collective

Medical Volunteer Information

Signup for one 4hr Saturday TeleConsult CallShift

Dates of Travel | International Medical Mission Work

Workload Tolerance

Other Information