Free Clinic of the Twin Counties Patient Application

FREE CLINIC OF THE TWIN COUNTIES PATIENT APPLICATION

Clinic Use Only: Paid:______

Clinic card expires: ____/____/_____

Income Verification:____ Tax Form___ W2___

Letter____ Other______Income______

NAME: (First)______Middle______LAST______

Former Last Name______

ADDRESS______CITY______STATE______

ZIP CODE______DOB______SSN______

MARITAL STATUS: ___Single ___Married___ Divorced___ Legally Separated____ Never Married __ Widowed

SEX: ___Female ___Male HOME PHONE:_____ - _____-______CELL_____-_____-______WORK_____-_____-______

E-MAIL______( Pease provide for portal) CONTACT PERFERENCE______

PATIENT PORTAL REGISTRATION ____Yes ____ NO CONSENT TO TEXT______ARE YOU HOMELESS______VERTERAN_____

ARE YOU EMPLOYED______If yes, where? ______Pay Rate______

How did you hear about us?______

HOW MANY PEOPLE LIVE IN YOUR HOME______ARE YOU LIVING WITH RELATIVES______

HOUSEHOLD INCOME______DO YOU GET FOOD STAMPS______HOW MUCH______

PRIMARY LANGUAGE______SECOND LANGUAGE (if any) ______

PREFERRED PHARMACY______CITY OF PHARMACY______

RACE______ETHNICITY______

RELEASE MEDICATION/MEDICAL INFORMATION ______Yes ______NO

NAME: ______ADRESS______CITY______STATE______

EMERGENCY CONTACT NAME ______PHONE______

ADDRESS ______CITY______STATE______ZIP______

APPLICANT SIGNATURE______DATE______

OFFICE SIGNATURE ______DATE ______

FREE CLINC OF THE TWIN COUNTIES INFORMATION WITH TERMS AND CONDITIONS

FOR PROSPECTIVE AND RENEWAL PATIENTS

CRITERIA: The Free Clinic of the Twin Counties works hard to provide patients with quality medical care. To receive services at TFC (The Free Clinic) you will need to meet some criteria:

• You must have lived in the Twin County area (Carroll, Grayson, or City of Galax) for a minimum of six months.

• Household income must be 200% or less of the Federal Poverty Level.

• You must be completely uninsured (No Medicare, Medicaid, Veteran’s Benefits, or Private Insurance).

WHERE TO APPLY: You may apply for services at:

THE FREE CLINIC OF THE TWIN COUNTIES

140 Larkspur Lane, Suite C

Galax Va. 24333

How to apply: You will need to complete a short application providing us with information about yourself and your household. After you are determined eligible for services, TFC can schedule your first appointment if you need to see one of our providers. Eligibility for services is for a 12 month period and eligibility will need to be re-examined every 12 months.

When to Apply: Applicants may apply Tuesday through Thursday, 9:30-11:30 am. & 1:00 - 4:00 pm.

NOTE: WE DO NOT PRESCRIBE CONTROLLED SUBSTANCES INCLUDING NARCOTICS AND BENZODEAZIPAMS ( i.e. Xanax, Klonopin, Atavan, Valium).

Proof of Income: When you come to the clinic to apply for services, please bring with you at least 1 form showing Proof of Income: Bank Statements, Notices from Social Security, Paycheck Stubs, Food Stamp notices, Child Support Information, Alimony Check/ Copy of Court Order, etc.

TFC will take into consideration total household income so you will be required to bring proof of total household income.

Termination: Eligibility for services through TFC will end if you begin to receive medical insurance of any type or if your income should increase beyond the stated limits. If you are found to have insurance while you are a FREE CLINIC patient, your services will be terminated.

FREE CLINIC OF THE TWIN COUNTIES

PROOF OF INCOME

• Pay Stubs – Provide either the most recent with “Year to Date” income listed

• W-2 Form – Or Income Tax Return for most current calender year

• Unemployment Notice – From VEC ( Virginia Employment Commission)

• Statement of Social Security Benefits – Or other benefits

• Food Stamp - Letter of Eligibility

• Alimony Check – Or copy of Court Order

• Child Support – Information or Court Order

FREE CLINIC OF THE TWIN COUNTIES

HEALTH QUESTIONAIRE

NAME:______DOB: ______

PAST MEDICAL HISTORY

Blood Type __A __AB__B__O __ Positive __Negative__ Unknown

HEAD RESPIRATORY

__Trauma __Asthma

__Bronchitis

EYES __COPD – Bronchitis/Emp

__Blindness __Pleuritis

__Cataracts __Pneumonia

__Glaucoma

__Wear Glasses/Contacts GASTROINTESTINAL

__Cirrhosis

EARS __GERD

__Hearing Aid __Gallbladder Disease

__Heartburn

NOSE/SINUSES __Hemorrhoids

__Allergic Rhinitis __Hepatitis

__Sinus Infection __Hiatal Hernia

__Jaundice

MOUTH/THROAT/TEETH __Ulcer

__Dentures

__Partial

__Plates GENITOURINARY

__Hernia

CARDIOVASCULAR __Incontinence

__Aneurysm __Nephrolithiasis

__Angina __Other Kidney Disease

__DVT __STDs

__Dysrhythmia __UTI(s)

__Hypertension

__Murmur MUSCULOSKELTAL

__Myocardial Infarction __Arthritis

__Other Heart Disease __Gout

Explain:______M/S Injury

SKIN NEUROLOGICAL

__Dermatitus __Epilepsy

__Mole(s) __Seizures

__Other Skin Condition(s) __Severe Headaches

__Psoriasis __Stroke

__TIA

PSYCHIATRIC

__Anxiety ENDOCRINE

__Bipolar __Goiter

__Depression __Hyperlipidemia

__Hallucinations, Delusion __Hypothyroidism

__Suicidal Ideation __Thyroid Disease

__Suicide Attempts __Type I DM

__Type II DM

HEME/ONC INFECTIOUS

__Anemia __AIDS

__Cancer __HIV

__ STDs______

__Tuberculosis (dz)

__Tuberculosis ( exposure)

PAST SURGICAL HISTORY

COMMON SURGERIES:

__Aneurysm Repair __Knee Arthroplasty

__Appendectomy __LASIX

__Laminectomy

__Back Surgery __Nasal Surge

__Bariatric Surgery __PTCA/PCI

__Bilateral Tubal Ligation __Pacemaker/Defibrillator

__Breast Resection/Mastectomy __Prostate Surgery

__Carotid Endarterectomy/Stent __Prostatectomy

__Carpal Tunnel Release Surgery __Rotator Cuff Surgery

__Reverse Tubal Ligation __Sinus Surgery

__Cataract/Lens Surgery __Skin Cancer Excision

__Cesarean Section __Spinal Fusion

__Cholystectomy/Bile Duct Surgery __TAH-BSO

__Dilation & Curettage __Tonsillectomy/Adnoidectomy

__Hemorrhoid Surgery __Vasectomy

__Hip Arthroplasty __Gallbladder

__Hip Replacement __Kosh Punch Placement

__Hysterectomy

__Inguinal Hernia Repair

SOCIAL HISTORY

TABBACCO USAGE

__Current Daily Smoker DRUG ABUSE CARDIOVASCULAR

__Former Smoker __IVDU __Eat Healthy Meals

__Never Smoker __Illicit Drug Use __Regular Exercise

__No Illicit Drug

__Take Daily Aspirin

ALCOHOL

__Do Not Drink

__Drink Daily SAFETY

__Frequent Drinker __Household Smoke detectors

__Hx of Alcoholism __Keep Firearms in Home

__Occasional Drinker

SEXUAL ACTIVITY

__Exposure to STI

__Homosexual Encounters

__Not Sexually Active

__Safe Sex Practices

__Sexually Active

CURRENT MEDICATIONS

Name :______Dosage:______

DRUG ALERGIES

Drug______Reaction______

FAMILY HISTORY

Please List any strong family diseases:

__Arthritis __Heart Attack

__Asthma __High Cholesterol

__Bleeding Disorder __Hypertension

__COPD __Mental Illness

__Diabetes __Osteoporosis

__Heart Disease __Stroke

__Seizure Disorder __Alcoholism

__Tuberculosis __Drug Abuse

__Colon Cancer __Thyroid Disorder

__Uterine Cancer __Breast Cancer

__Ovarian Cancer __Other Cancer

WOMEN:

Age of Menstruation _____ Age of Menopause______

___History of Abnormal PAP Smear ___History of Fertility Drug Use

___History of irregular Menses ___Unable to become pregnant

PREGNABCY HISTORY:

Total Pregnancies_____ Full Term_____ Miscarriages______Abortions_____ Living_____

MEN:

Prostate Trouble __Yes __No Weak Stream __Yes __No Impotence/Difficulty with Erections__Yes___No

Use of Viagra or other ED medications ___Yes ___No