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.

Fields marked * are required

First Name*
Last Name*
Date of Birth:
Do you have health insurance? :
Do you have a primary care doctor? :
Please provide your email address if you have one
Street
City
State/Province
Zip*
Please provide a phone number where you can be reached*
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?:

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2022 FEDERAL POVERTY LEVELS

Size of Household	150% monthly	150% yearly	200% monthly	200% yearly	250% monthly	250% yearly
1	$1,699	$20,385	$2,265	$27,180	$2,831	$33,975
2	$2,289	$27,465	$3,052	$36,260	$3,814	$45,775
3	$2,879	$34,545	$3,838	$46,060	$4,797	$57,575
4	$3,469	$41,625	$4,625	$55,500	$5,781	$69,375
5	$4,059	$48,705	$5,412	$64,940	$6,764	$81,175
6	$4,649	$55,785	$6,198	$74,380	$7,747	$92,975
7	$5,239	$62,865	$6,985	$83,820	$8,731	$104,775
8	$5,829	$69,945	$7,772	$93,260	$9,714	$116,575

Patient Questionnaire