SECURE REGISTRATION FORM: Complete this form to register for any classes or services. If you are preregistering, notify the reception desk you have already registered when you arrive. We have two classes during the day on Saturdays: 10am and 2pm.The classes are free and start promptly at 10am and 2pm, with space limited to 10 seats per class. Attendance is on a first-come, first-serve basis. Registration closes when the class starts (either 10a or 2p). Ten (10) minutes after the class begins, we will ask new arrivals to come back for the next class.
Classroom for Naloxone Administration and Food Handlers Training
First 2 letters of first name
First 2 letters of mother's first name
Middle Initial or Middle Name (optional)
2-digit year of birth
Address (Can be work or home, etc.)
Telephone Number with Area Code
Sex at Birth
Is this your first time visiting Gallup Health Cooperative?
Which services are you preregistering for? (optional)
STI Treatment Referral and Information
Results from a Test I Already Received Here
Syringe Services and Supplies
Narcan/Naloxone Training Class (Naloxone is available separate or with Food Handler)
STI and Syphilis Test Only (No HIV Test)
Food Handlers Training & Naloxone Administration (Food Handler is after 15 min Naloxone Training)
I have general questions
Sexual Health Screening (General)
I just need to know my status
Hepatitis Screening (Rapid HCV test)
About what time do you plan on arriving?
The 10am Class (space is limited to ten attendees, arrive early!)
The 2pm Class (space is limited to ten attendees, arrive early!)
Services other than classes: 11am to 2pm
Unknown Arrival Time
Do you have a primary physician? (optional)
I need a referral list to help me find a primary physician
Where do you receive healthcare? (optional)
Indian Health Services (IHS)
Private Practice / General MD
Navajo Nation Department of Health
I need help acquiring health care or insurance
Are you experiencing any symptoms? (check the best answer)
I don't know
Someone told me to get checked for a possible issue
Someone texted or called me stating I have a possible infection (STD, Hepatitis, HIV, etc.)
Yes (We have no nurses or doctors on site, and will need to refer you to treatment/care)
I believe I possibly got exposed to something, but I have no symptoms
Something minor has me concerned, but I'm not sure if it is an infection.
How did you hear about us?
Radio Spot (KTNN, KGAK, etc.)
Social-Networking Smartphone App (Facebook, Grindr, etc.)
Express Visit (initial here if you want the "Express Screening")
If I have requested a sexual health screening, such a rapid HIV, Syphilis or HCV exam, I just want the express visit service. I do not need a counselor to speak with me about the details on how these infections are transmitted nor do I need the counselor to ask me questions about reducing my risk to certain infections, such as HIV and Syphilis. I realize if I leave this section without circling it, that the counselor may take the recommended time to ask me questions about reducing my risk to infection. (If you are not having a sexual health screen, please leave this area unmarked)
Would you like the "Express Screening" today? (optional)
I don't know
Signature (type your name or initials)
Send me a copy of my responses.
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of Gallup Health Cooperative.