This application will take about 15 minutes to complete. Please have all of your medical history, all medications you're currently taking, and personal information available before you start.

Income and residency documents can be emailed to eligibility@willinghelpersclinic.com

Once the form is submitted, you will receive a phone call from our clinic on our next business day to schedule your first eligibility appointment. If you do not show for your eligibility appointment, you will not be able to schedule an appointment to see a doctor.

Social History:

Vaccinations:

Family Medical History:

For each relative, please list any diseases, and if they are still living/the cause of death:

Medical History:

Current Medications:

Please list:

• name of any current medications you're taking

• the dose/strength

• any instructions

Please email all income and residency documents to eligibility@willinghelpersclinic.com as soon as possible. We cannot schedule your eligibility appointment until all required documents have been received.

After all documents are submitted, our clinic will contact you on the next business day to schedule your eligibility appointment. If you miss this appointment, you will not be eligible to schedule a provider visit.