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Health Services Check-In Forms.

Please complete the following information. Until you submit your final answers, you can go backward and forward to change responses. If you want to pause and continue later, you may do so by exiting the survey. When you are ready to restart, enter the survey using the same link and the same device. If you have any issues while filling this out, please call us at 308-696-1201. For special accommodations, please call 308-221-6623.

This form is not for COVID-19 Testing. For testing information, please go to our service tab and click on COVID-19 Resources.

*If you do not already have an existing appointment, a WCDHD staff member will reach out to you for scheduling.

Patient Information

Please indicate the following:

I am completing this information on behalf of myself.
I am completing this information on behalf of my child or person of which I am the guardian.
I am filling this out on behalf of someone else that is not my child or that I am not the guardian of.

Please indicate the following:

I am seeking to schedule an appointment (WCDHD staff member will call you for scheduling)
I have scheduled an appointment (please provide date of scheduled appointment)

Best phone number to reach you at:

Demographics for patient (please put NA for fields that do not apply):

First Name

Middle Initial

Last Name

Birthdate

Age

Gender

Social Security #

Marital Status

Address (please put NA for fields that do not apply):

Address

Apt #, Suite, etc.

City

County

State

Postal code

Country

Ethnicity:

Hispanic or Latino
Not Hispanic or Latino

Race:

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other