LMV VILLAGE & CLINIC REPORT

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**LMV Form 11**

Fill out one full report for each clinic conducted.
Submit by email attachment to:
LMV corporate trip coordinator
LMV corporate secretary
Each chapter vice president
LMV executive director

Village Name:
Country:
Start Date (mm/dd/yy):
End Date (mm/dd/yy):

Submitted By (Name):
(Chapter):

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**Contacts**

Presidente:
Comisario:
Pasante:
Nurse/Clinic Worker:
Other:

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**LMV Members Participating** 

For each member, include Name, Chapter, and Volunteer Skill. Include yourself.
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2. 
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8. 
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11. 
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13. 
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15. 
16. 

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**Clinic Equipment**

For each, indicate W for "working", N for "nonworking", or M for "missing".

Water: 
Sterilization: 
Electricity: 
Amalgamator: 
Chair: 
Compressor: 
Other: 


** Equipment/Supplies Left Behind**

For each item, indicate Location and Contact.
1. 
2. 

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**Comments on Cooperation, Clinic Condition/Problems/Needs**



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**Health Professional Report**

Services Provided (Medical, Dental, Optometry, etc.)?

LMV Dr.'s Name:

# of Patients (Total):
# of Children:
# of Women:

Please indicate numbers for the following activities/procedures below.

Cleanings:	 
Eyeglasses: 
Restorations: 
Prescriptions: 
Extractions: 
Other: 


**Specific Medical Problems Encountered**

For each listed, indicate whether it needs follow-up (Indicate Y for "yes", N for "no").
1. 
2. 
3. 
4.


**Other Medical Comments**



**Next Trip Recommendations**

For health professional recommendation, Indicate Y for "yes" or N for "no".
Medical: 
Doctor: 
Optometrist: 
Dentist: 
Other Specialist: 
Hygienist: 

No later than date (mm/dd/yy): 

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**Specific Items for Follow-Up**

For each, indicate Item and Description. Corporate trip coordinator is to complete "Action Taken" for each item and return form to chapter trip coordinator.

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LMV Village & Clinic Report	Form Last Updated 4/20/06