City of Victoria Form Center

2. First Name*
3. Last Name*
5. Name
6. Email Address*
8. Address
10. City
11. State
12. Zip Code
14. Phone Number*
16. Would you like a free health screening?*

    Members of the Victoria Fire Department will provide basic vital signs checks, glucose assessment and heart screening. They will also be able to answer basic health questions and provide information on what types of incidents are appropriate for an emergency room and what would be better seen at an urgent care clinic or doctor’s office.

    1. Yes
    2. No
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

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