Patient Questionnaire

Image of an older White man doctor writing on a navy blue clipboard and sitting in a bright white and beige office

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?:

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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