Scheule An Appointment - Wellness Screening Roseville

Scheule An Appointment - Wellness Screening at Aŋpétu Téča Community Center

Tuesday, November 18, 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
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. Do NOT include ID and group number. This screening is free to you and does not bill insurance.
Select an Appointment Time at Aŋpétu Téča Community Center
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Scheule An Appointment - Wellness Screening at Aŋpétu Téča Community Center