Patient Questionnaire

Confirmation – your form has been successfully submitted!

Thank you for submitting a Patient Questionnaire and taking the first step towards better health outcomes for yourself or for another individual in your life. You should be contacted by a Patient Health Advocate within the two business days. If you have any questions regarding your submission, please don’t hesitate to call our direct line at 904-595-7770.

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?:

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

Patient Questionnaire