Pilsen Wellness Center Resource Fair

This form is confidential. We share this information with our care management teams to help manage your care. This form tells us what we need to know to help you achieve a healthy pregnancy.

Once you complete the form, you will earn a $50 reward on your CountyCare Visa Rewards Card.
Our care management team will reach out to you once you submit this form.

Follow these steps:
Step 1: Complete all member information
Step 2: Complete the prenatal care provider information.
Step 3: Submit the form.

Fields marked with an * are required

This form is confidential. We share this information with our care management teams to help manage your care. This form tells us what we need to know to help you on your health journey.

Once you complete the form, you will earn $20 on your CountyCare Visa Rewards Card. Our care management team may reach out to you once the form is submitted. 

Follow these steps:

Step 1: Complete all member information
Step 2: Complete all questions within the health survey
Step 3: Submit the form

Fields marked with an * are required

This form is for CountyCare members ages 13 years and older. Parents or guardians can complete the survey on behalf of their minor children by entering their child's Member ID and Date of Birth. To complete the survey on your phone, text the word “SURVEY” to 84908.