Care Connection

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If you are in crisis STOP. Call 911 or our Emergency Services Department at 239-275-4242.

How can SalusCare Help? (Please select all the below statements that apply to you.)

Section 1

Address*
Mailing Address

Section 2

Date of Birth*
Do You Require a Translator?
Please type detailed information about any allergies you may have

Section 3

Emergency Contact Address
Legal Guardian Contact Address

Section 4

Do you currently have health insurance?
Are you registered to vote?