Please attach a signed copy of the What’s That contract, email it to jon@rasinfoundation.org or mail to Rasin Foundation 202 Edge Hill Road, Milton MA 02186.
Note: After clicking send you may see a spinning icon but your application has been sent, please hit send only once.

    Thank you for your interest in the Rasin Foundation and our What's That clinical consult service. This program links health care providers from around the world with our clinic staff in Leogane Haiti. The goal is fo provide real time consultation to improve the clinical care provided at our Health Center in Leogane.

    Your Name (required)

    Your Email (required)

    Your Cell Phone Number (required)

    Please indicate which consult networks you would like to participate in:

    By checking this box, you indicate that you have read the Clinician Consent to Participate form and agree to the terms outlined in it.

    Optional
    Please email or attach your signed consent form:

    Please attach your license:

    Thank You