Inquiry Form

Open Arms Free Clinic is a community-supported health clinic. We provide free services of medical, dental, and mental health care for people in Walworth County who do not have health insurance and cannot afford to pay for care. People who have state insurance (Medicaid or BadgerCare) are eligible for our dental-only serivces.

After you fill out this form, someone from our team will contact you. We will talk with you to see if you qualify for our services and help you take the next steps.

Please note: The clinic is open Monday through Thursday. We will do our best to contact you within one business day.

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Full Name *
Date of Birth (Month-Day-Year) *
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DD
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What is your preferred spoken language? *
Mobile Phone Number (xxx)-xxx-xxxx *
Do you give permission to receive text messages from Open Arms Free Clinic?

Note: Messages are only for clinic communication and will not be sold or shared with other parties.
 *
Email address (optional)
Street Address (if currently unhoused, type NONE) *
City  (if currently unhoused, type NONE) *
Zip  (if currently unhoused, type NONE) *
Do you have health insurance? *
What services are you interested in? (check all that apply) *
Required
Thank you for reaching out to Open Arms Free Clinic. A team member will contact you within one business day to see if you would qualify for our services. Please look for a phone call from (262) 379-1401.
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