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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2023 FEDERAL POVERTY LEVELS

Size of Household	150% monthly	150% yearly	200% monthly	200% yearly	250% monthly	250% yearly
1	$1,823	$21,870	$2,430	$29,160	$3,038	$36,450
2	$2,465	$29,580	$3,287	$39,440	$4,108	$49,300
3	$3,108	$37,290	$4,143	$49,720	$5,179	$62,150
4	$3,750	$45,000	$5,000	$60,000	$6,250	$75,000
5	$4,393	$52,710	$5,857	$70,280	$7,321	$87,850
6	$5,035	$60,420	$6,713	$80,560	$8,392	$100,700
7	$5,678	$68,130	$7,570	$90,840	$9,463	$113,550
8	$6,320	$75,840	$8,427	$101,120	$10,533	$126,400

Patient Questionnaire