FREE CLINIC OF THE TWIN COUNTIES PATIENT APPLICATION

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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 VERTERAN CONSENT TO TEXT ARE YOU HOMELESS 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 HEAD Trauma EYES Blindness Cataracts Glaucoma Wear Glasses/Contacts EARS Hearing Aid NOSE/SINUSES Allergic Rhinitis Sinus Infection MOUTH/THROAT/TEETH Dentures Partial Plates Blood Type A AB B O CARDIOVASCULAR Aneurysm Angina DVT Dysrhythmia Hypertension Murmur Myocardial Infarction Other Heart Disease Explain: SKIN Dermatitus Mole(s) Other Skin Condition(s) Psoriasis PSYCHIATRIC Anxiety Bipolar Depression Hallucinations, Delusion Suicidal Ideation Suicide Attempts Positive Negative Unknown RESPIRATORY Asthma Bronchitis COPD Bronchitis/Emp Pleuritis Pneumonia GASTROINTESTINAL Cirrhosis GERD Gallbladder Disease Heartburn Hemorrhoids Hepatitis Hiatal Hernia Jaundice Ulcer GENITOURINARY Hernia Incontinence Nephrolithiasis Other Kidney Disease STDs UTI(s) MUSCULOSKELTAL Arthritis Gout M/S Injury NEUROLOGICAL Epilepsy Seizures Severe Headaches Stroke TIA ENDOCRINE Goiter Hyperlipidemia Hypothyroidism Thyroid Disease Type I DM Type II DM

HEME/ONC Anemia Cancer INFECTIOUS AIDS HIV STDs Tuberculosis (dz) Tuberculosis ( exposure) PAST SURGICAL HISTORY COMMON SURGERIES: Aneurysm Repair Appendectomy Laminectomy Back Surgery Bariatric Surgery Bilateral Tubal Ligation Breast Resection/Mastectomy Carotid Endarterectomy/Stent Carpal Tunnel Release Surgery Reverse Tubal Ligation Cataract/Lens Surgery Cesarean Section Cholystectomy/Bile Duct Surgery Dilation & Curettage Hemorrhoid Surgery Hip Arthroplasty Hip Replacement Hysterectomy Inguinal Hernia Repair Knee Arthroplasty LASIX Nasal Surge PTCA/PCI Pacemaker/Defibrillator Prostate Surgery Prostatectomy Rotator Cuff Surgery Sinus Surgery Skin Cancer Excision Spinal Fusion TAH-BSO Tonsillectomy/Adnoidectomy Vasectomy Gallbladder Kosh Punch Placement 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 Frequent Drinker Hx of Alcoholism Occasional Drinker SAFETY Household Smoke detectors Keep Firearms in Home SEXUAL ACTIVITY Exposure to STI Homosexual Encounters Not Sexually Active

Safe Sex Practices Sexually Active CURRENT MEDICATIONS Name : Dosage: DRUG ALERGIES Please List any strong family diseases: Arthritis Asthma Bleeding Disorder COPD Diabetes Heart Disease Seizure Disorder Tuberculosis Colon Cancer Uterine Cancer Ovarian Cancer FAMILY HISTORY Heart Attack High Cholesterol Hypertension Mental Illness Osteoporosis Stroke Alcoholism Drug Abuse Thyroid Disorder Breast Cancer Other Cancer

WOMEN: Age of Menstruation History of Abnormal PAP Smear History of irregular Menses Age of Menopause History of Fertility Drug Use Unable to become pregnant PREGNABCY HISTORY: Total Pregnancies Full Term Miscarriages Abortions Living MEN: Prostate Trouble Yes No Weak Stream Yes No Use of Viagra or other ED medications Yes No Impotence/Difficulty with Erections Yes No

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