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 STEP ONE of the online patient application. Once we have received the completed application, a representative of the Clinic will reach out to you within 2 business days with final steps.

If additional forms are needed to determine your eligibility, you can find and download them here.

NEW PATIENTS:

IF YOU DO NOT HAVE HEALTH INSURANCE, PLEASE PROCEED TO STEP ONE OF THE APPLICATION:

STEP ONE: NEW PATIENT APPLICATION

NEW PATIENT APPLICATION - ENGLISH

SOLICITUD PARA PACIENTE NUEVO - ESPAÑOL

 

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 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