FreeHouse Community Clinic
Please utilize this form for scheduling care at Revolution Wellness Center's FreeHouse Community Clinic as a NEW FreeHouse Patient. 

If you are an EXISTING FreeHouse Patient, please call or text Revolution at 763-425-4577 for scheduling. Please include in your text or by phone that you are an Existing FreeHouse Patient so the staff can schedule you accordingly.

Revolution Wellness Center is located at 10800 Old County Road 15 in Plymouth, MN (55441). We can be contacted with questions by phone at 763-425-4577.

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Today's Date
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First & Last Name *
Date of Birth *
Email Address *
Phone Number *
FreeHouse is open the 2nd and 4th Tuesday of each month. 

Please indicate the date and time you plan to attend FreeHouse as a NEW Patient; please only select ONE time slot. You will be seen during your time slot but care will be on a first come first serve basis. 

The clinic closes at 5pm. Our staff needs to close at the end of shift so it is your responsibility to have transportation by or before 4:30pm.

If you are an EXISTING Patient at FreeHouse, please contact Revolution by phone or text at 763-425-4577 for scheduling. This form is for NEW FreeHouse patients only.
2:00pm-3:00pm
3:00pm-4:00pm
4:00pm-5:00pm
Tuesday February 11th
Tuesday February 25th
Tuesday March 11th
Tuesday March 25th
New Patient Paperwork

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Required
Please indicate which of the following qualifications you meet to participate in FreeHouse. You MUST bring proof of what qualifies you to your first appointment.
Indicate how you qualify for FreeHouse Community Clinic if not listed above:
FreeHouse Expectations & Agreements

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Please confirm the following is correct:
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