Patient Questionnaire

Image of an older White man doctor writing on a navy blue clipboard and sitting in a bright white and beige office

Patient Questionnaire

This questionnaire is intended for those seeking care for themselves or for someone in their life. If you are a community organization or hospital partner, please use the client referral form. 

Before submitting this form, please note that JaxCareConnect helps uninsured individuals connect to primary care services and community resources that support their health and well-being. We are not a health insurance provider, urgent care center, or emergency medical service. If you are experiencing a medical emergency, call 911 or seek immediate medical attention.

Fields marked * are required



Date of Birth:
Do you have health insurance? :
Do you have a primary care doctor? :






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.

What is your family size? (Include yourself, your spouse/partner, children under 18, students under 21, and unborn children) :
Are you employed?:
What is your estimated household income for the past 4 weeks? :
Please describe your most immediate needs and level of urgency:
Are you the patient completing this application or are you completing this application for someone else?*
Is there anything else we should know?:

2026 FEDERAL POVERTY LEVELS

Size of
Household		200%
monthly		200%
yearly		250%
monthly		250%
yearly		300%
monthly		300%
yearly
1$2,660$31,920$3,325$39,900$3,990$47,880
2$3,607$43,280$4,508$54,100$5,410$64,920
3$4,553$54,640$5,691$68,300$6,830$81,960
4$5,500$66,000$6,875$82,500$8,250$99,000
5$6,447$77,360$8,058$96,700$9,670$116,040
6$7,393$88,720$9,241$110,900$11,090$133,080
7$8,340$100,080$10,425$125,100$12,510$150,120
8$9,287$111,440$11,608$139,300$13,930$167,160