New Patient Paperwork

Today's Date *

Personal Information

First Name *

Last Name *

Date of Birth *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Background

Income & Insurance

Prayer

Do you want to pray with our prayer team during your visit? *

Religious Preference

Guardian Information

If a patient is under the age of 18, please complete the information below.

Parent/Guardian Name

Relationship

Parent
Guardian

DOB

Release of Information & Consent for Treatment

I, ___________ hereby give Grace Clinic of Ohio permission to release health records and/or give verbal information about my health to any and all healthcare providers from whom I may seek additional care or treatment arising from and reasonably related to the services provided by Grace Clinics of Ohio. I also give any and all healthcare providers from whom I may seek additional care or treatment from and reasonably related to the services provided by Grace Clinics of Ohio, permission to obtain copies of health records and/or to receive verbal information about my health. I understand that the information released and/or obtained will be used only for the purposes of providing care at Grace Clinics of Ohio or for other reasons only after a release has been signed for that particular purpose. *

Please initial here.

I, ___________ hereby consent to the provision of care, diagnosis and/or treatment by the Grace Clinics of OHio and I hereby acknowledge that such consent will remain in effect unless and until I cancel such consent in writing. I hereby acknowledge and confirm that I am mentally capable of giving informed consent to the provision of the care, diagnosis and/or treatment and am not subject to duress or under undue influence. *

Please initial here.

Review of Patient Rights & Responsiblities

I have read and I understand the Patient Rights & Responsibilities as posted in Grace Clinics of Ohio. I have had the opportunity to ask questions or request explanation from a volunteer and/or staff member/ *

Please initial here.

I authorize Grace Clinics of Ohio to use my photos/videos for promotional materials, advertisements, social media, and other communications, without payment. This permission applies to all formats and markets, now and in the future, and continues indefinitely unless I revoke it in writing. I understand these materials will become the property of Grace Clinics of OHio and will not be returned. I release Grace Clincis of Ohio from all liability related to the use of these materials. *

Please initial here.

I have read and I understand the Telemedicine Consent Form, and authorize Grace Clinic of Ohio to allow me/the patient to particpate in a telemedicine (video conferencing service). *

Please initial here.

I have read and I understand the notice of Limited Liability for Free Clinic Volunteer Health Care Professionals, Board Members, Officers, Employees, and Independent Contractors as posted in Grace Clinic of Ohio. Being mentally competent and under no duress or undue influence, I am giving informed consent to the qualified immunity that extends to health care providers of Grace Clinics of Ohio, Inc. who provide diagnosis, care, or treatment as long as no compensation is received or expected and is provided in a free clinic. *

Please initial here.

Personal Information

Background

Income & Insurance

Prayer

Guardian Information

Release of Information & Consent for Treatment

Review of Patient Rights & Responsiblities

Past Medical History

Get Updates Sent To Your Inbox

Psalm 34:18

“The Lord is close to the brokenhearted and saves those who are crushed in spirit.”