CFC Gynecology Clinic Appointment Request
CFC Gynecology Clinic occurs every other month. The Gynecology Clinic offers free pap smears, breast exams, STI testing, and mammogram referrals. If you would like to be contacted for an appointment during the next Gynecology clinic, please provide responses to the questions below. People will be contacted in the order that requests are received.
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First and Last Name *
DOB *
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Phone Number *
Email *
Address (Street name, City, State, Zip)
 *
Are you a Franklin County Resident? *
Marital Status *
Preferred method of contact *
Who is your emergency contact & what's their relationship to you?
 *
Emergency contact number
 *
Race (Check all that apply) *
Pflichtfrage
Are you Hispanic/Latino? *
What is your preferred language? *
Would you like an interpreter for this visit? *
Residency Status *
Employment *
Insurance Status *
Type of housing *
How many people live with you? *
Yearly Income *
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