Free Clinic Forms

 Below are common forms used within the office.

Please feel free to fill out and print the forms at home and then bring them with you to the Free Clinic.

This may save time during your visit to the office.

 

 

New Patient Registration Form

 

 

Informed Consent and Waivers

 

 

Deemed Consent for Blood Testing

 

 

FCRC Consent for Treatment

 

 

Patient Authorization Form

 

 

Chronic Disease Patient Contract 

 

 

Medications Assistance Program

 

 

 

         

Hours of Operation:

Monday thru Thursday: 8:00AM – 12:00noon and 1:00PM - 4:00PM

***Walk-ins are not accepted***

     
 
 
 

Registered Mark of the Blue Cross and Blue Shield Association is an independent licensee
of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield of North Carolina
Foundation is a licensed affiliate of Blue Cross and Blue Shield of North Carolina.
http://www.bcbsncfoundation.org/