Form - Health Care Clinic

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Superior, WI Location

1406 Belknap St., Superior WI 54880

Ashland, WI Location

422 3rd Street West Suite 205, Ashland, WI 54806

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Our Services
About Us
Get Involved
Fees
Donate
Contact Us
- Schedule Online

Legal First Name

Legal Last Name

Date of Birth

Email

Location Preference

Superior Ashland First Available

I want to schedule an appointment for the following services (Check all that apply)

Birth Control Emergency Contraception Pregnancy Testing Sexually Transmitted Infection Testing UTI Testing Vaginal Infection Testing (Yeast/Bacterial Vaginosis) Pap Smear

Current Symptoms (Check all that apply)

Positive home pregnancy test Missed period Discharge Pain/burning Bumps/sores/rash I do not have any symptoms currently

Method of Payment

I have Wisconsin Medicaid I am a UWS student I would like to enroll in Family Planning Only Services (see eligibility requirements here) I prefer to pay out of pocket (see sliding fee discount requirements here)

Agree

By submitting this form I agree to receive email communication from Health Care Clinic.

Regardless of sex, gender, age, income, marital status, race, religion, national origin, sexual orientation or gender identity.

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