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?:

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