Patient Application

Volunteer

The free clinic and/or individual health care professional provides a patient a written notification explaining that the patients’ legal liability is limited pursuant to the Public Health Service Act.

Click HERE to download our patient application.

Below is an income eligibility guideline.

Household Size       300% FPG

          1                        $35,310
          2                        $47,490
          3                        $60,270
          4                        $72,750
          5                        $85,230
          6                        $97,710
          7                        $110,190
          8                        $122,670