Services Request Form

Company Name*

First Name*

Last Name*

Email*

Phone Number*

Street Address*

City*

State/Region*

Potential Date for On-site Services

Month/Day/Year

Other Potential Dates

Number of Employees/Expected Participants*

Which OCH Services are you interested in?

Education Sessions (Interactive health education sessions with community health workers.)

Health Insurance Enrollment (Washington and Oregon Medicaid, or other insurance options.)

Vaccines and Illness Prevention (Flu, tetanus, Covid-19, and other diseases.)

Medical Mobile Clinic (Visits with a provider, testing for common health concerns, blood pressure checks, and more.)

Other