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🏥 Chicagoland Health Fiesta Registration Form / Formulario de Registro

\n\n

\n Name / Nombre:
\n \n

\n\n Date of Birth / Fecha de Nacimiento:
\n \n

\n\n Gender / Género:
\n \n

\n\n Address / Dirección:
\n \n

\n\n City / Ciudad:
\n \n \n\n State / Estado:
\n \n \n\n Zip Code / Código Postal:
\n \n

\n\n Phone Number / Número de Teléfono:
\n \n

\n\n Email Address / Correo Electrónico:
\n \n

\n\n Preferred Language / Idioma Preferido:
\n \n

\n\n Race/Ethnicity / Raza/Etnicidad: (optional / opcional)
\n \n

\n\n

\n 📋 Screenings and Services You Are Interested In / Servicios y Exámenes que Le Interesan:\n Blood Pressure Screening / Examen de Presión Arterial
\n Diabetes Screening / Examen de Diabetes
\n Vision Screening / Examen de la Vista
\n Hearing Screening / Examen de Audición
\n Mental Health Information / Información sobre Salud Mental
\n Senior Services / Servicios para Personas Mayores
\n COVID-19 Vaccines / Vacunas contra COVID-19
\n Other / Otro
\n

\n\n \n

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