NorthShore Health Centers Mobile Unit Request Form
Please fill out the form below to request our mobile unit to come to your location.
Organization Name
Contact Name
First Name
Last Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Requested Date (30 Day notice is required for visits requesting medical services)
-
Month
-
Day
Year
Date
Time of Event
Location Requested for Mobile Unit
Type of Mobile Visit
Bus Only
Medical Services
Additional Services:
Screenings (Include specific screening requests in the comment section)
Community Health Worker
Health Education
Insurance Navigator
Who referred you?
Comments (please include where you'd like us to park the mobile unit)
Submit
Should be Empty: