Forma de Registro para la feria de salud

FORM TO REGISTER FOR OUR HEALTH FAIR.

Por favor llene la siguiente forma. Si tiene preguntas llamenos al: 720-208-0163 Please fill out the following form. If you have questions call us at: 720-208-0163

 

First Name

 

Last Name

 

Is this person a minor? (Less than 18 years old)

 

Date of Birth

 
mm/dd/yyyy
 

Language

 

Phone Number

Phone
 
 

Do you consider yourself Latino/a?

 
 

Address

 

City

 

State

 

Zip Code

 
 
 

Examenes de Salud - Marque los examenes que le gustaria

Health Screenings - Mark the screenings that you would like to receive

 

Cholesterol Test

 

Kidney Test

 

Blood Pressure

 
 

Escoja un horario para recibir las vacunas y/o examanes

Pick a time to receive your vaccines and/or exams.