PATIENT APPLICATION ONLINE
Once you have determined your eligibility to become a patient at the Free Clinic [determine eligibility here or call 843-266-9800] please proceed to fill out the online patient application below.
Please note that before you can schedule an appointment at The Free Clinic, you will need to complete a New Patient Application and be accepted as a new patient. You will be asked to provide the following information:
- Patient Information
- Medical History
- Consent for Treatment
- Patient Eligibility Application
Once we have received your New Patient Application, a representative of the Clinic will reach out with next steps. Should additional forms be required, you can download them from the list below.
IF YOU DO NOT HAVE HEALTH INSURANCE, PLEASE PROCEED TO THE APPLICATION:
CURRENT PATIENTS:
IF YOU ARE AN EXISTING PATIENT AND WOULD LIKE TO RENEW YOUR APPLICATION-
This form is to be completed ONLY if you are a patient and your eligibility has expired. This application must be completed on an annual basis.
PATIENT RENEWAL FORM - ENGLISH
FORMULARIO DE RENOVACIÓN DEL PACIENTE - ESPANOL
SUPPLEMENTAL FORMS
You may be required to submit additional information to verify your eligibility. A representative of the staff will let you know. All forms can be viewed and downloaded below. Once you have completed your paperwork, you may upload it via your patient application account, emai applications@bifmc.org or drop them off directly at the clinic.
SUPPLEMENTAL FORMS, ENGLISH / ESPANOL
Attestation Of Physical Address, English / Confirmación De La Dirección Física
Room And Board Form, English / Alojamiento
No Income Form, English / Para Personas que no tienen ingresos
Employer Statement Of·Income Form, English / Declaración De Ingresos Por El Empleador
English 
Español de México