New Patient Forms

Welcome to The Doctors’ Volunteer Clinic. Patient intake forms are available below. Please print and fill out the patient registration forms below prior to coming to the Clinic for your first appointment.

To be a patient and receive treatment at the clinic, you must meet our eligibility guidelines:

• Patients must not have private insurance or government-provided insurance such as Medicaid or Medicare.

• Patients must meet the financial guidelines of living 250% below the federal poverty level. View the current standards for FPL.

Please bring the following to your first appointment:

• Photo ID

• New patient form (See links to forms below.)

• Income verification documents, we accept any of the following:

  • Tax Return

  • W-2

  • Paycheck stubs

  • Social Security statement of earnings

  • Disability statement of earnings

  • Proof of SNAP (food stamp) benefits

  • Bank statements

  • Letter from employer 

We accept donations to help us continue offering these services.