Patient Information Sheet

Please correct the errors described below.

Northern Neck - Middlesex Free Health Clinic Patient Information

Last Name

First Name

Middle Initial

Date of Birth

Social Security Number

Sex

Street Address 1

Street Address City

Street Address State

Street Address Zip Code

Mailing Address 1

Mailing Address City

Mailing Address State

Mailing Address Zip Code

County of Residence

Marital Status

Veteran

No Yes

U.S. Resident

No Yes

Race

Home Phone

Cell Phone

May we text you?

No Yes

Email Address

May we contact you using this address?

No Yes

Emergency Contact

Emergency Contact Phone

Relationship

At which hospital have you been recently treated?

Who is your family physician?

How did you hear about the clinic?

Highest Completed Education Level

Number of Family Members

Patient Employment Information:

Employment Status

Unemployed Since

Employer

Employer Phone Number

Date Hired

Employer Address 1

Employer City

Employer State

Employer Zip Code

Second Job / Spouse / Other Income

Employment Status

Unemployed Since

Employer

Employer Phone Number

Date Hired

Employer Address 1

Employer City

Employer State

Employer Zip Code

Did you previously have health insurance?

No Yes

If so, when did it end?

This information will only be used to determine financial eligibility and/or provide medical or dental treatment at the Clinic.

By checking this box I give my consent for this information to be used for this purpose.

I understand that knowingly providing false information on the above form may make me ineligible for services at NNMFHC. I also understand that it is my responsibility to inform the clinic if any of this information should change.

Date Submitted

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