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  • English (US)
  • Thank you for your interest in being a patient of the Free Clinic of Culpeper.

    Our online application process consists of four parts. Each of the four parts of the application must be submitted for your application to be processed and your screening appointment to be booked.

    ELIGIBILITY APPLICATION 
    ELIGIBILITY REQUIREMENTS & AGREEMENT
    MEDICAL HISTORY
    CONSENT AGREEMENTS & PERMISSIONS


    Please click NEXT to begin.

  • ELIGIBILITY FORM

  • GENERAL CONTACT DETAILS


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  • CONSENT TO CONTACT
    Please indicate how we may contact you.

  • EMERGENCY CONTACT DETAILS
    Please provide us with an emergency contact. (i.e. someone that you want the clinic to notify in the event of a life threatening situation).

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  • DEMOGRAPHIC DETAILS
    Please provide us with your demographic information to better allows us to understand certain background characteristics of our patients.

  • EMPLOYMENT DETAILS
    Please provide us with your employment information to better allows us to understand certain employment background of our patients.

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  • HOUSEHOLD DETAILS
    Please provide us with your employment information to better allows us to understand certain employment background of our patients.

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  • I, {fullName}, by signing below, understand and agree that;

    • All the information on this form is true and accurate to the best of my knowledge.
    • All documents provided are genuine and accurate.
    • I agree to comply with the terms of eligibility as set forth by the Free Clinic of Culpeper.
    • I do not have any health care insurance, including Medicare and Medicaid, or insurance that would provide prescription medication coverage.
    • In the event I receive RxPartnership or other IPAP medications, I give my permission for their representative and affiliated pharmaceutical companies to review my medical records for proof of eligibility for audit purposes.
    • I agree to notify the Free Clinic of Culpeper immediately of any changes in income, insurance status, or household size.
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