Mailchimp Survey

Clinic Interest Questionnaire

Please tell us about your containerized clinic project! We will review your questionnaire submission and reach out to set up a meeting to discuss how Clinic In A Can can help with your project.

*Note* Submitting this form is not the same as placing an official order. You will not be charged for submitting this form nor for your initial consultation. Subsequent consultations may be subject to a standard Clinic In A Can design fee.

First Name
Last Name
Organization
Your Address
Please provide a good phone number where you can be reached:
Email
Where is your clinic destination? Please include country, state and city (if possible).
How soon will you need your clinic(s)?
1-3 months4-6 months1 year +
What size would you like your clinic(s)?
20ft Standard Single Exam Room (112sqft)
20ft XL Single Exam Room (127sqft)
20ft Split Double Exam Room (53sqft per room)
40ft Single Exam Room (includes an exam room, a waiting/entrance area, and an ADA bathroom)
40ft Quadruple Exam Room
53ft Single Exam Room (includes an exam room, a waiting/entrance area, an ADA bathroom, and a storage area)
4-Unit Community Health Center (four 20ft Split Double Exam Room units)
4-Unit Community Health Center Economy (two 20ft Split Double Exam Room units and two 20ft storage containers))
6-Unit Community Health Center (five 20ft Standard Single Exam Room units and one 20ft Split Double Exam Room unit)
Other (please explain below)
If your response to the previous question was “Other,” please explain.
What will this clinic be used for? Ex. Primary care, emergency room, radiology, etc.
Will you need your clinic outfitted with medical equipment from Clinic In A Can?
YesNo
What is the local electricity voltage and hertz for the clinic’s destination?
110 volt
220 volt
50 Hz
60 Hz
How will you power your clinic?
Local Grid/ Local Power Company
Solar Power
Diesel Generator
Hybrid Power (a combination of Solar Power and a Diesel Generator)
Local Grid/ Local Power Company with a backup generator
Do you wish to source your power system from Clinic In A Can (i.e. purchase the Solar/Generator/Hybrid system from CIAC)?
YesNo
Will your clinic be off-grid and need a separate water system?
YesNo
Would you like the option for hot water?
YesNo
Do you need data and telephone ports for your clinic?
YesNo
Do you need a negative pressure fan?
YesNo
On average, what are the hottest and coldest temperatures your clinic destination experiences each year? Please specify Celsius or Fahrenheit.
Will local or state authorities require a permit for your clinic?
YesNoUnsure
Will the clinic need a third party inspection and a full set of stamped architectural and engineering plans?
YesNoUnsure
Do you have any other comments or information you’d like to share about your clinic project?

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