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  • Community Clinic Request Form

    Community Clinic Request Form

    Request for a Larimer County Department of Health and Environment Clinic

  • We are excited with the prospect of partnering with you. To help us determine if we can fulfill your request, please provide as much information as possible on this form.

    Important Notes:

    • Please provide at least three weeks advance notice of the event whenever possible.
    • As an equity-based community clinic provider, our goal is to reduce barriers to acccessing vaccines and sexual and reproductive health services.
    • Populations we are able to serve in the community include the following:
      • Vaccines
        • Uninsured or underinsured individuals ages 6+
        • Individuals with Medicaid ages 6+
      • Sexual and Reproductive Health
        • Uninsured or underinsured individuals
        • Individual seeking confidential care
        • Individuals with Medicaid

    Please note that not all requests can be accommodated. A staff member will coordinate with you within five business days regarding your request.

  • Event Contact Information: 

  • Format: (000) 000-0000.

  • Event Details

  • Date Request for Community Clinic (order of preference)
     - -
  •  - -
  •  - -
  • Community Clinic Setting

  • Additional Event Details

  • Please indicate which of the following can be provided at the event (check all that apply):
  • Please indicate which clinical services you are requesting for the event (check all that apply):

  • Community Clinic - Vaccines

  • If the community clinic will provide VACCINES for individuals ages 6–19, please indicate which vaccines are being requested (check all that apply):
  • If the community clinic will provide VACCINES for individuals over 19 years, please indicate which vaccines are being requested (check all that apply):

  • Community Clinic - Vaccines AND Sexual and Reproductive Health

  • If the community clinic will provide VACCINES for individuals ages 6–19, please indicate which vaccines are being requested (check all that apply):
  • If the community clinic will provide VACCINES for individuals over 19 years, please indicate which vaccines are being requested (check all that apply):
  • Please indicate the privacy accommodations at the site to determine which SEXUAL AND REPRODUCTIVE HEALTH services can be provided (check one option). A staff member will review the sexual and reproductive health services available based on your response.

  • Community Clinic - Sexual and Reproductive Health

  • Please indicate the privacy accommodations at the site to determine which SEXUAL AND REPRODUCTIVE HEALTH services can be provided (check one option). A staff member will review the sexual and reproductive health services available based on your response.

  • Thank you for taking the time to complete the community clinic request form. Please click the "submit" button and an LCDHE staff member will reach out within five business days.

  • Should be Empty: