Client Referral Form

Office Closure Notice

JaxCareConnect will be closed December 23 through December 26, as well as January 1 and January 2. During this time, referral processing and responses may be delayed. We appreciate your patience and will resume normal operations on the next business day. For 24/7 immediate urgent care (FREE for uninsured), please call Healthlink Jax at 904-925-2273 or visit their website by clicking on the button below.

Click Here for Healthlink Jax

Fields marked * are required

What is today's date? :
Client First Name
Client Last Name
Date of Birth:
To your knowledge, does your client have health insurance?:
Client's Street
City
State/Province
Zip
Please provide a phone number for your client*
Would your client like to recieve SMS alerts?
YES! By checking this box your client is consenting to receive text message alerts several times per month. Messaging and data rates apply. View our privacy policy.

Please provide an email address for your client
To your knowledge, is your client at or below 300% of the current Federal Poverty Guidelines? :
Does your client have a language preference? :
Please describe your client's immediate medical needs and level of urgency. :
Referrer's Name*:
Referrer's Organization*:
Referrer's Phone*:
Would you like to recieve SMS alerts?
YES! By checking this box you are consenting to receive text message alerts several times per month. Messaging and data rates apply. View our privacy policy.

Referrer's Email*:
What is your relationship to the Client?:
Please include additional notes regarding this client that would be useful for our team to know.:

2025 FEDERAL POVERTY LEVELS

Size of Household	200% monthly	200% yearly	250% monthly	250% yearly	300% monthly	300% yearly
1	$2,608	$31,296	$3,260	$39,120	$3,912	$46,944
2	$3,525	$42,300	$4,407	$52,884	$5,289	$63,468
3	$4,442	$53,304	$5,552	$66,624	$6,663	$79,956
4	$5,358	$64,296	$6,697	$80,364	$8,037	$96,444
5	$6,275	$75,300	$7,845	$94,140	$9,414	$112,968
6	$7,192	$86,304	$8,990	$107,880	$10,788	$129,456
7	$8,108	$97,296	$10,135	$121,620	$12,162	$145,944
8	$9,025	$108,300	$11,282	$135,384	$13,539	$162,468

Client Referral Form