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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Consent to Text ? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Referral Source {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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Chronic Care Management

Chronic Conditions? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ 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 }
{ binding firstError.message }

We have limited Flu vaccine voucher from Walgreen.

Flu shot ? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Food InSecurity?

Food is important  to health. we want to make sure you have enough food and the right type of food, so we ask all our patients these questions that have been applicable in last 12 months.

I worried that the food I bought will not last, before I got money to buy more {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ 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}
{ binding firstError.message }
Phone Cell {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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 }
{binding displayValue}
{ binding firstError.message }

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 }
{binding displayValue}
{ binding firstError.message }
zipcode {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Race {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone : Home {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Consent to Text ? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Referral Source {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Reason for Visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Chronic Care Management

Chronic Conditions? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Pre-Requiste {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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 }
{binding displayValue}
{ binding firstError.message }

We have limited Flu vaccine voucher from Walgreen.

Flu shot ? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Food InSecurity?

Food is important  to health. we want to make sure you have enough food and the right type of food, so we ask all our patients these questions that have been applicable in last 12 months.

I worried that the food I bought will not last, before I got money to buy more {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Cognito Forms{{ Cognito.resources["powered-by-cognito"] }}