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
Solicitud de renovacion en linea
If you would like to download paper application forms and return them to Clinic, you can find them here:
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.
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