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?:

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

Patient Questionnaire