Screening Request
We aim to assist people to the right care, right place, and right time. To become a patient of Open Arms Free Clinic, a person must live or work in Walworth County, Wisconsin and have qualifying income documents to access our free health and wellness services. By submitting this screening request, you can expect a call from the Open Arms team to schedule a complete telephone screening that will help to determine if the free clinic services are appropriate for you.
Email address *
This screening request is for: *
Your full name (if this is not for you) *
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy