Scheule An Appointment - Wellness Screening 1.30.2025

Scheule An Appointment - Wellness Screening at Christ the King Lutheran Church

Thursday, January 30, 2025 - Appointments Available from 9:30 to 3:00
Name

First NameLast Name
Birth Date

MonthDayYear
Gender Identity

MaleFemaleNon-BinaryOther
Race/Ethnicity (Check All That Apply)

African BornAfrican- AmericanBiracialCaucasian /WhiteHispanicLatino / Latina / LatinxNative AmericanAsianPacific IslanderOther
Is your yearly income less than $25,700?

YesNo
Mailing Address

Street Address

Apartment Number Needed to mail you results

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Would you like a reminder?

Yes, please call me.Yes, please text me.No, I do not want a phone reminder.
Check All That Apply

I am a Veteran.I am a Caregiver.I identify as a member of the LGBTQ community.
Who is your health insurance provider. ID and group number not needed. This screening is free to you and does not bill insurance.
Select an Appointment Time at Christ the King Lutheran
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Scheule An Appointment - Wellness Screening at Christ the King Lutheran Church