Appointment Request Form

All new Patient MUST email or text us Proof of Income or Letter of support to (904) 419-8006 or info@massclinic.org
Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date of Birth ( Age 18+ )

Are you new patient? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Appointment Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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New Patient

By submitting the request, I affirm that I don't have any type of insurance and my last 30 days gross household income is less than 200% below the federal poverty line. I will submit my proof of income or Letter of Support

 

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Zipcode 322xx

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Referral Source {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Urgency? This appointment is urgent. Add me to waiting list. If available, I can come within 24 hour notice. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Appointment Request Form

Appointment Request Form

All new Patient MUST email or text us Proof of Income or Letter of support to (904) 419-8006 or info@massclinic.org
Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Phone Cell {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you new patient? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Appointment Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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New Patient

By submitting the request, I affirm that I don't have any type of insurance and my last 30 days gross household income is less than 200% below the federal poverty line. I will submit my proof of income or Letter of Support

 

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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zipcode {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Race {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone : Home {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Referral Source {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Reason for Visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pre-Requiste {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Urgency? This appointment is urgent. Add me to waiting list. If available, I can come within 24 hour notice. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Cognito Forms{{ Cognito.resources["powered-by-cognito"] }}