Patient Forms

Before you schedule an appointment at The Free Clinic, you will need to complete a New Patient Application which can be accessed online here.

Once we have received Step One of the New Patient Application, a representative of the Clinic will send Step Two which will ask for the following information:

  • Patient Information
  • Medical History
  • Consent for Treatment
  • Patient Eligibility Application

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

NEW PATIENT APPLICATION: STEP ONE

Solicitud de paciente nuevo: primer paso

If you would like to download paper application forms and return them to Clinic, you can find them here:

Patient Application, English (paper)

La Solicitud De Paciente Nuevo, Espanol (papel)

 

RENEWAL APPLICATION

Renewal Application Online

Solicitud de renovacion en linea

If you would like to download paper application forms and return them to Clinic, you can find them here:

Renewal Patient Form, Paper

Formulario de renovación del patiente, en papel

 

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.

If you are unable to upload the required forms on your application, please email the forms to info@bifmc.org
Please note, you will be unable to make an appointment without submitting all necessary forms.

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

Patient Privacy Policy English / La Clínica Gratuíta Barrier Islands Normas de Confidencialidad