Free Health Center Patient Form

If you are un-insured and would like to express interest in enrolling into Medical Care at the Neighborhood Resilience Project, please complete this form.

Please know that this form is only to be used to express interest in enrolling in the Free Health Center. The Free Health Center is not a walk-in clinic. A staff member will be in touch with you to officially enroll you and schedule you for your appointment.

Free Health Center Patient

Patient Interest Enrollment Form

Do you have Health Insurance(Required)
Have you had an established relationship with a Primary Care Doctor?(Required)
Back to Top