Bausch Foundation MEDICAL MISSION PROGRAM

Bausch Foundation
Medical Mission Program Application
Rx Pack

 Please note, you must complete the forms and submit them properly before your application is complete. Expedited service to meet travel deadlines and deliveries to Alaska and Hawaii incur additional charges.

Partner Organization Information

Click on the buttons below to complete each form separately or select the bottom link to complete both. Both the Eligibility Packet (Partner Organization Information) and Practitioner's Agreement must be completed before shipments are approved.

Eligibility Packet Form

PopInBlue_ELS_Eligibility Packet Form

Practitioner's Agreement Form

PopInBlue_ELS_Practitioners Agreement Form

Eligibility Packet with Practitioner's Agreement

PopInBlue_ELS_Eligibility Packet Form with Practitioners Agreement