Kirkland Free Medical & Dental Clinic - Appointment Request Form
Date: Saturday, February 27, 2021 ONLY
Clinic Address: 6400 108th Ave NE, Kirkland, WA 98003
Contact us at Kirklandfreeclinic@gmail.com
Email address *
Last Name *
First Name *
Age *
Phone Number *
What type of visit would you like? *
What is the reason you are coming to see the doctor or dentist? *
By clicking "yes" and submitting this form, I understand that I do NOT yet have an appointment until I receive an email stating that I am confirmed for an appointment and given an appointment time. *
Required
By clicking "yes" and submitting this form, I understand that the clinic is ran by 100% volunteers so I will be patient with receiving an email confirmation of my appointment time. *
Required
By clicking "yes" and submitting this form, I agree to being placed in an email and text message list servers for Kirkland Seventh-day Adventist Church and Hawker Center for Integrative Medicine so that I can receive communications via email and text messages. *
Required
By clicking "yes" and submitting this form, I understand that the appointment time given to me will be the time I must show up by or else I forfeit my appointment slot. *
Required
By clicking "yes" and submitting this form, I understand that the clinic has limited availability and services so there is a possibility I will either be placed on a waitlist or not receive an appointment at all. *
Required
By clicking "yes" and submitting this form, I agree to abide by ALL COVID prevention guidelines required of me by the clinic. *
Required
A copy of your responses will be emailed to the address you provided.
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