US Free & Charitable Clinic Application

US Free & Charitable Clinic Application

MedShare will be able to support many of your clinic's needs for medical supply items. As a non-profit, we may not have everything you need in our inventory at all times so we will not be able to be your primary supply source. However, utilizing our services will help free up your funds so you can serve the greatest needs in your community. Once your application is confirmed, you will receive an email and be able to order items online for the greatest selection, or visit our Decatur, GA location by appointment to choose selected items in our Primary Care Center.
Today's date

MonthDayYear
Date
Name of Clinic / Organization*
Organization Website*
examplesite.org
Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Contact Email*
example@example.com
Clinic / Organization Address*

Street Address

Street Address Line 2

CityState

Zip Code
Which COUNTY is this in?*
Please indicate the Local COUNTY in which your clinic operates. This is important, as we seek grant funding to help offset the costs of acquiring, storing and delivering donated supplies and equipment, and many are county-specific. Thank you!
Are you a member of your state's Free and Charitable Clinic association?

YesNoNot Sure

Please provide the name of the contact person we can reach out to for the detailed Demographic and Financial information.
Name 2*

First NameLast Name
Email 2*
example@example.com
Phone Number 2*
Please enter a valid phone number.
Recipient Agreement
Should be Empty:

General Information