340 Printers Parkway

Colorado Springs, CO 80910

 

Customer Service Center:

719-632-5700

 

Find us on Facebook

 

 

 

 

 

 

  Please complete the form below and click Submit Form.

 
Please fill in all fields marked with a *
Name *
TodaysDate
BusinessAddress
HomeAddress
City
State
ZipCode
WorkPhone
CellPhone
Specialty
How did you learn about volunteer opportunities at Peak Vista Community Health Centers?

Volunteering can provide many personal rewards. Why do you feel you would like to volunteer at PVCHC?

Have you previously/or do you currently volunteer? If yes, where and when?
What kinds of services are you willing to provide? (surgery, consult, etc.)

Are you fluent in any other language than English? If so, please list:

Types of services you are willing to provide (surgery, consult, etc.)

Preferred location for volunteer services: Your Office Your Office
Preferred location for volunteer services: PVCHC Clinic PVCHC Clinic
Hospital affiliations:
Do you have medical liability insurance? Check If yes: Yes
Do you have medical liability insurance? If yes, please specify:
Do you give PVCHC permission to bill payers for services you provide? Yes
Do you give PVCHC permission to bill payers for services you provide? No
Available Monday Monday

Write in preferred hours for Monday:

Available Tuesday Tuesday
Write in preferred hours for Tuesday:
Available Wednesday Wednesday
Write in preferred hours for Wednesday:
Available Thursday Thursday
Write in preferred hours for Thursday:
Available Friday Friday
Write in preferred hours for Friday:
HowSoon
Comments