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.

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.

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

NEW PATIENT APPLICATION

Solicitud de paciente nuevo

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

Paper Application, English

Formulario de renovación del patiente, (en papel)

RENEWAL APPLICATION ONLINE:

Renewal Application Online

Formulario de renovación del patiente

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

Renewal Application, English (paper)

Formulario de renovación del patiente, en papel

Supplemental Forms/ Additional Information:

You may be required to submit additional information to verify your eligibility via Wellvista, which can be found here: Welvista Online Application.

Welvista is a patient assistance program used to obtain prescription medications as needed. A representative of the staff will let you know should any information be missing.

Welvista Online Application

-Attestation Of Physical Address *To be utilized if you do not have a photo ID or an ID that matches your address

-Room And Board Form *To be utilized if you are living with someone who is supporting you

-No Income Form *To be utilized if no one in your household has an income

2025 Employer Statement Of·Income Form *To be utilized if you do not have pay stubs

ALL SUPPLEMENTAL FORMS CAN BE FOUND HERE: Welvista Online Application

Patient Privacy Information:

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