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.
What is your full name?
Cómo se llama? (ex: John Smith)
What is your telephone number
Cuál es su número de teléfono?
What is your primary email address?
Cuál es su correo electrónico?
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.)
Well Patient Check Up
High Blood Pressure, Diabetes, or High Cholesterol
If you checked "medication refill" above, do you need to speak with a physician?
Have you been seen at the Clinic Before?
Yes, and I have been assigned a student as a part of the Longitudinal Patient program
If you are part of our Longitudinal Patient program, what is your student's name?
The following questions pertain to additional services offered by the Columbus Free Clinic. Please check the corresponding box if you respond "yes."
Are you interested in mental health resources?
Do you need help applying for health insurance?
Do you need information on accessing food assistance?
None of the above
Please complete the captcha before submitting the form.
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