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Lloyd F. Moss Free Clinic
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Patient Intake
Patient Intake
New Patient Profile Form
Name*
Address 1
Address 2
City
State
Zip
Phone #
May we text you?
Yes
No
Email*
Date of Birth
Monthly Income
Include Spouse, Social Security, Unemployment, Child Support and all other income.
Number of People in Household
This is the same number claimed on taxes.
Do you have health insurance?
Yes
No
Do you have Medicaid?
Yes
No
Do you have Medicare?
Yes
No
Do you have medical coverage through the Veteran's Administration?
Yes
No
Have you ever been a patient of the Lloyd F. Moss Free Clinic?
Yes
No
Who was your last Health Care provider?
How long has it been since you have seen a healthcare provider?
Why do you need to see a healthcare provider?
When can you come in?
Monday
Morning
Mid-Day
Afternoon
Evening
Tuesday
Morning
Mid-Day
Afternoon
Evening
Wednesday
Morning
Mid-Day
Afternoon
Evening
Thursday
Morning
Mid-Day
Afternoon
Evening
Friday
Morning
Mid-Day
Afternoon
Evening
Here's a list of documents you'll need in order to receive services:
Please indicate if you have the document or not.
Document 1
Yes
No
Document 2
Yes
No
Document 3
Yes
No
Document 4
Yes
No
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