Sliding Scale Application

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First name

Email

Do you have health insurance?

Household size

Last name

Phone

Annual household income

I understand that I must provide proof of eligibility to qualify for the sliding fee scale discount.

Do you qualify for any of the following programs?

SNAP

WIC

Free/Reduced School Lunch

TANF

Disability Benefits

Thank you!

We’ll be in touch soon.

7612 W. North Avenue

2nd Floor

Elmwood Park, IL 60707

Phone: 708-240-3874

Fax: 773-598-8022

First Name

Last Name

Email

Client's name and age

How can we support you?

Thanks for submitting!

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