Form Center

2. ¿No hablas inglés? Use el formulario en español para comunicarse con el departamento de salud pública.

4. Have questions about COVID-19 vaccinations? You can:

   • Visit our Vaccine page's Frequently Asked Questions
   • Submit a question on our COVID-19 Vaccine form
   • Call our CARES Team at 602-506-6767 or email them at CaresTeam@Maricopa.gov.
6. Disclaimer
   • Please do not submit confidential information, this form is not secure.
   • Required fields are highlighted in pink and/or marked with a red asterisk.
8. Topic:*
   -- Select One --Air QualityBirth and Death CertificatesContact the DirectorDisease Investigation and DataEmergency PreparednessHealth Code and Regulations (Environmental)ImmunizationsInternships and VolunteersMediaOral Health ProgramsOther Clinical Services (TB, Hansens)Report a Problem (Mold, Mosquitoes, Insects)Restaurant / Food Establishment ConcernsSchools --- Infectious DiseasesSchools --- Nutrition, Physical Activity, Teen Pregnancy, and Tobacco PreventionSTD TestingStudent RequestsWomen, Infants and Children (WIC)Other

   Please select a topic from the list above that best reflects your area of concern.

10. First Name:*
11. Last Name:*
13. Email:*
14. Phone:*
16. City:
17. Zip/Postal Code:
19. Question/Comment:*
21. Response Deadline:
    Response Deadline:
22. Contact Me By:
    -- Select One --EmailPhoneNo Response Needed
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field