Columbus Free Clinic RETURNING PATIENT Appointment Request
**If this is a medical or mental health emergency please call 911 or go to the closest emergency room.

**If you have been the victim of a crime please call 911 or go to the closest emergency room.

The Columbus Free Clinic will be CLOSED on Thursday, 11/28 for Thanksgiving. 

Thank you for choosing Columbus Free Clinic for your healthcare needs. 

This form is for RETURNING patients to request an appointment for next Thursday (appointments start at 5:40pm). If you have never been seen by Columbus Free Clinic, please return to the website and select the "New Patients" option.

If you submit this form but do NOT get a phone call from us by next Tuesday, we were unable to get you scheduled this week. Please try again Friday morning or leave us a voicemail or send us a message at 614-404-8417 especially if you have submitted the form multiple times.

If you need an appointment sooner or would like to check out other clinics in the area, we recommend visiting the additional resources section of our website here: https://columbusfreeclinic.com/community-resources/

Please note that we are unable to see patients positive for Covid-19 at this time. 
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First name: *
Last name: *
Do you have a preferred name?
Date of birth: *
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/
DD
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YYYY
Sex: (assigned at birth) *
Race: (Check all that apply) *
Required
Current address: *
Phone number: (Primary) *
Does this phone number receive text messages:
 *
Email address: *
Preferred method of contact: (Check all that apply) *
Required
Emergency contact name:
 *
Emergency contact relationship: *
Emergency Contact Phone Number *
Health insurance status: *
Do you plan to be in Columbus/Central OH for next 6 months:
 *
Preferred language: *
Would you prefer an in-person or telehealth (via phone) appointment:
 *
Preferred appointment time: (Thursdays 5:40PM-8:00PM) *
Are you experiencing any challenges making it to your appointment (transportation, time, etc.)?
 *
Marital/relationship status:
 *
How many people live in your household including yourself:
 *
Language spoken at home: *
Sexual orientation: *
Gender: *
Personal pronouns:
Have you served in the United States military: *
Education: *
Current employment status: *
Personal yearly income: *
Household yearly income: *
Reason for your visit: (Please be detailed) *
Allergies to medications: *
List all the medications you are taking, INCLUDING dose: (ex: Sertraline, 50mg) *
Current/previous health conditions: *
Are you currently pregnant? *
Previous surgeries: *
Preferred pharmacy name and address? *
Are you interested in services from: (Check all that apply) *
Required
Are you coughing up bloody mucus? *
Have you recently experienced fevers, night sweats, weight loss, cough, or shortness of breath?
 *
Have you recently traveled to or emigrated from Latin America, Southern Africa, Eastern Europe, or Asia? *
Do you or the people you live with work in healthcare or the prison system?
 *
Do you authorize CFC to access your medication history automatically from pharmacy benefit managers (grant us medication history authority)? *
Electronic Signature (Write first AND last name) *
Alternate Signature (If this Columbus Free Clinic Consent is signed by someone other than the patient, it must be signed in the patient’s presence. Please include your relationship to the patient below. You may type N/A if the signature above belongs to the patient.)
By submitting this form you consent to receive texts and phone calls from our clinic about your care. You also consent to be treated by the staff of the Columbus Free Clinic.
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