Clinic Survey.v2

Start typing the name of your clinic and if your clinic is already known by CCHF you will see it on the list. When you select your Clinic Name, the address fields will be prefilled.

If you don't find your clinic above

Clinic Authorized Primary Contact

Please fill out the contact details of the person who will be updating your clinic information. NOTE: We require your birthdate and the last 4 digits of your Social Security number to verify your identity and keep your clinic information safe. 

Page 3

CEO/Executive Director

Medical Director

About Your Clinic

How would you describe your clinic's on-site pharmaceutical services? (If your clinic operates multiple sites, more than one answer may apply. 

(best guess)
What Percentage of Your Patients Are (best guess):

You Clinic's Staff

Student Program Coordinator

Your Signature and Payment

Clinic membership annual dues are based on a sliding scale relative to your organization's annual budgeted revenue. Suggested donation amounts are: 

Annual Budget Suggested Amount
1) <$150,000 $225
2)  $150k-$499k $400
3)  $450k-$749k $600
4)  $750k-$1.1M $900
5)  $1.2M-$2.9M $1,350
6)  >$3M $1,700
7) +$100 for every million above $3M



Payment Information

Signature of Authorized Clinic Representative