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:

Patient Application, English (paper)

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 Patient Paper Application

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

Welvista Online Application

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