Notice to patient: You are being referred to a volunteer health care provider, who will provide care to you or to someone for whom you are legally responsible. Your participation in this referral process is voluntary. The care you receive from the volunteer health care professional will be provided at NO CHARGE to you.

Patient acknowledgement: The information I have provided regarding my eligibility, income, and insurance is true and complete to the best of my knowledge. My signature confirms that I meet the above criteria and agree to provide a copy of last year's tax return or other financial documentation, if required. I also acknowledge that failure to provide the clinic with an update on financial or health insurance status may result in disqualification to receive health care under the clinic. I further understand that falsification of any information in this form constitutes automatic disqualification from the clinic.

I certify that I do NOT have Medicare, Medicaid, or private insurance.