Free Clinic Patient Application
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  • New Patient Application Checklist

    Please make sure all items are included with the application. We do not accept the application without all the information needed. Required fields are marked with an asterisk. Thank you!
  • Included Documents:
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  • Browse Files
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  • New Patient Registration

  • Date of Birth*
     - -
  • Gender*
  • Are you a US Citizen?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Income listed is per:*
  • Are you disabled?*
  • If yes, have you applied for disability?
  • Are you unemployed?*
  • If yes, have you applied for unemployment?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have any type of insurance?*
  • Have you applied for Medicaid or Medicare?*
  • Marital Status*
  • Ethnicity:*
  • Format: (000) 000-0000.
  • Date*
     / /

  • Free Clinic of Meridian Patient Health History

  • Date of Birth*
     / /
  • Date last seen*
     / /
  • Check if you had any of the following:*
  • Are you allergic to anything?*
  • Are you currently out of any medications?*
  • Date*
     / /

  • Free Clinic of Meridian Authorization to Verify Patient Information

  • Date of Birth*
     / /

  • I hereby authorize the Free Clinic of Meridian to verify my income and availability of insurance by contacting my employer, my spouse's employer, the Mississippi Office of Medicaid, and/or the Office of Medicare.

    I understand that having a household income above 200% of the Federal Poverty level for a household of my size or having any type of insurance will disqualify me from receiving care at The Free Clinic of Meridian.

  • Date*
     / /

  • QUESTIONNAIRE FOR PATIENTS WITH NO INCOME

    If you presently DO NOT have any income coming into your household, please answer the following:
  • 1. Has anyone in your HOUSEHOLD received income this month such as cash, checks, gifts?
  • 2. Have you received financial assistance through any of the following community agencies in the past three months?
  • Do you receive child support?
  • Should be Empty: