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Free Health Clinic Registration Form (2024)
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* Indicates required question
Email
*
Your email
Patient's First Name
*
Your answer
Patient's Last Name
*
Your answer
Gender
*
Male
Female
Age Group
*
18 to 30 Years
30 to 50 Years
50 to 65 Years
65 Years and above
Phone (Must be valid number to contact you)
*
Your answer
Email (Must be valid email to contact you)
*
Your answer
Do you have insurance? (No Insurance needed but please disclose if you are insured in USA to avoid any charges and get discounted testing options if test suggested by physicians)
*
Yes
No
Are you taking any medication? (Remember all medications while attending health fair to let physician know)
*
Yes
No
Select the monthly clinic day you will come for the checkup. (*Dates are subject to change)
*
Choose
Sept 29
Oct 27
Nov 17
Dec 15
How did you hear about this free clinic?
*
Choose
Temple Newsletter
Temple Notice Board
Temple Facebook Account
Friends Referred
Other
NOTE: Register each family member separately.
Patients will have an option to get blood work done based on physician recommendation from partner labs with discounted charges.
A copy of your responses will be emailed to the address you provided.
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