Free Medical Clinic

Patient Application

Last Name

First Name

Date

Address

City

State

Zip

Home Phone

Work Phone

Alternate Contact

Do You Currently Have Medical Insurance?

□    Yes

□    No

Medical Needs / Reason for Visit

Brief Description of Previous Medical Issues

Day Preference

□Mon    □Tues    □Wed    □Thurs     □Fri    □Sat    □Sun

Time Preference

Additional Information / Physical Assistance Needed

Referred by

For SSOLE Use Only

Date Received:

Date Contacted:

Notes:

Clinic Referred: