Patient Questionnaire

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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



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






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
150%
monthly
150%
yearly
200%
monthly
200%
yearly
250%
monthly
250%
yearly
1 $1,956 $23,475 $2,608 $31,296 $3,260 $39,120
2 $2,644 $31,725 $3,525 $42,300 $4,407 $52,884
3 $3,331 $39,975 $4,442 $53,304 $5,552 $66,624
4 $4,019 $48,225 $5,358 $64,296 $6,697 $80,364
5 $4,706 $56,475 $6,275 $75,300 $7,845 $94,140
6 $5,394 $64,725 $7,192 $86,304 $8,990 $107,880
7 $6,081 $72,975 $8,108 $97,296 $10,135 $121,620
8 $6,769 $81,225 $9,025 $108,300 $11,282 $135,384