Columbus Free Clinic Sign Up
Complete this form to sign up for this Thursday's clinic. You will receive a call on Wednesday evening with your appointment time. If the form is closed or you do not receive a call/ voicemail, unfortunately that means all clinic appointments are filled for the week. Please try again as early as Friday morning.
Email address
What is your full name?
Cómo se llama? (ex: John Smith)
Your answer
What is your telephone number
Cuál es su número de teléfono?
Your answer
What is your primary email address?
Cuál es su correo electrónico?
Your answer
How would you like to be contacted? (Como le gustaría ser contactado?)
An initial appointment reminder will be made by phone. This method of contact will be used for follow-ups, referrals, and other future communications. (Un recordatorio de la cita inicial se hará por teléfono. Este método de contacto se utilizará para el seguimiento, referencias y otras comunicaciones futuras.)
Please indicate the reason for your visit:
Por favor, explique la razón de la visita. (Please note, we are unable to offer STD or TB testing, immunizations, dentistry, or prenatal care.)
If you checked "medication refill" above, do you need to speak with a physician?
Have you been seen at the Clinic Before?
If you are part of our Longitudinal Patient program, what is your student's name?
Your answer
The following questions pertain to additional services offered by the Columbus Free Clinic. Please check the corresponding box if you respond "yes."
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This form was created inside of Columbus Free Clinic. Report Abuse - Terms of Service - Additional Terms