New Patient Application | themercyministries.org

Skip to content

Home
About
Team
Services
- Faith and Finances
Patients
Get Involved
Contact Us

Menu

Home
About
Team
Services
- Faith and Finances
Patients
Get Involved
Contact Us

New Patient Application

Thank you for applying to be a patient at Mercy Medical Clinic.

The following documents will be needed at your initial intake appointment:

All documents for proof of income (tax returns, food stamps benefit letter, 3 months of current check stubs if you or your spouse is employed)

If you do not have any income, you will be asked to complete a “Support Letter” at your visit
A copy of your picture i.d.
A copy of your social security card

Who referred you to our clinic? *

Email Address *

Before completing this form Do You Currently have Medical Insurance? *YesNo

Which clinic site would you need to use for services? *Lyons Campus: 714-1 NW Broad St. in LyonsGraham Campus: 454 Vernon Williams Rd. in Graham

Demographic Information

Full Legal Name *

Birth Date *

Social Security Number *

Sex *MaleFemale

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Cell Phone Number *

Home Phone Number

Do you give us consent to text and or call this number? *YesNo

Preferred Pharmacy *

Race/Ethnicity *

Patient Employer *

Marital Status *

Emergency Contact *

Relationship to the patient *

Phone Number *

Family Information

Is your spouse employed?YesNoI am not married

Spouse's Name

Spouse's Employer

Alternate Name and Phone Number of anyone we may contact fi unable to reach you or your emergency contact *

Financial Information

How many people live in your household? *

What is your household's total gross monthly income? (Include your spouse's wages) *

How many disabled children are in your custody? *

Please list your spouse and any dependents who currently live with you. Include relationship and age. *

Do you receive a check from Social Security? *YesNo

Do your spouse receive a check from Social Security?YesNo

Do any of your children receive a check from Social Security? *YesNo

Do you receive Unemployment Compensation? *YesNo

Do you receive Child Support/Alimony? *YesNo

Do you receive Food Stamps? *YesNo

Do you or your spouse receive retirement compensation? *YesNo

Are you a veteran? *YesNo

Do you have any other income not mentioned above? *YesNo

If you do not have any income, how do you live and pay household expenses?

Does someone help you or do you live with someone that helps you?

Medical Information

List any medical conditions, complains, problems or any other reason that you need to become a patient. *

If you have you recently been to the Emergency Room or admitted to the hospital, please tell us where.

If you have received any medical care within the last 12 months, please tell us where.

List any drug allergies. *

List all current medications.Include name and strength of medication AND how often you take it

Please check if you have had any of the following" *Heart Disease/Heart AttackStrokeHigh Blood PressureDiabetesColon PolypsCancerAllergiesKidney StonesTuberculosisAIDSMental IllnessBleeding DisordersAlcoholismAsthmaNone of the aboveOther

Other

List any surgeries. *

Have you ever had a joint OR heart valve replaced?YesNo

Do you require antibiotics prior to dental procedures?YesNo

Family History

Check if any blood relative has had any of the following: *Heart Disease/Heart AttackStrokeHigh Blood PressureDiabetesCancerAllergiesKidney StonesTuberculosisAIDSMental IllnessBleeding DisordersAlcoholismAsthmaNone of the aboveOther

Other

Is your Father still living? *YesNo

What was his cause of death and age at which he passed?

Is your Mother still living? *YesNo

What was her cause of death and age at which she passed?

Do you have any brothers or sisters?YesNo

If any of your brothers and sisters are deceased, what was the cause of death and age at which they passed?

Social History

How often do you exercise? *None1-3 times per weekMore than 3 times per week

Do you currently use any type of illegal drug(s)? *YesNoPrefer not to say

What type of illegal drug(s) do you use?

Have you used any type of illegal drug in the past? *YesNo

How often do you drink alcohol? *None1-3 times per weekMore than 3 times per week

How often do you smoke cigarettes? *Never1-5 per dayA pack a dayMore than 1 pack per dayOther

Do you use smokeless tobacco? *YesNo

Are you a former smoker? *YesNo

If you are a former smoker or a former user of smokeless tobacco, how long has it been since you quit?

Please do not fill in this field.

The Mercy Ministries

Our mission is to put God's love in action by providing healthcare to those in need.

Facebook Instagram

Home
About
Team
Services
- Faith and Finances
Patients
Get Involved
Contact Us

Home
About
Team
Services
- Faith and Finances
Patients
Get Involved
Contact Us

2023 The Mercy Ministries | Website by Odyssey

2023 The Mercy Ministries
Website by Odyssey

Close

Home
About
Team
Services
- Faith and Finances
Patients
Get Involved
Contact Us

Home
About
Team
Services
- Faith and Finances
Patients
Get Involved
Contact Us