Enrollment consent

Consent forms

• Arabic.
  • Fillable PDF version.
• Chinese.
  • Fillable PDF version.
• English.
  • Fillable PDF version.
• Russian.
  • Fillable PDF version.
• Somali.
  • Fillable PDF version.
• Spanish.
  • Fillable PDF version.
• Vietnamese.
  • Fillable PDF version.

Clients must complete this form to consent to enrollment for both programs listed below (as availability and eligibility allow).

• Health Navigation and Clinical Services through the Women's Wellness Connection (WWC).
• Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program.

Clients will remain enrolled as long as eligibility requirements are met and they do not request to be withdrawn from the programs.

 

More information on enrollment can be found in the Health Navigation and Clinical Services Administrative, and WISEWOMAN Program Manuals.