Fauquier Free Clinic
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  • Patients
    • Services
    • Eligibility
    • Patient Forms
  • Volunteer
  • Donate
  • News & Events
    • Charity Golf Tournament
    • Give Local Piedmont
    • Rappahannock Rough Ride
    • Expanded Care Plan
  • About Us
    • VHCF Dental Expansion Report
    • Strategic Plan
    • Meet Our Dental Team
    • Contact Us
    • Hours & Location
    • History
    • 2025 Annual Report
    • 2024 Annual Report
    • 2023 Annual Report

Patient Forms

Prepare for your Visit!


Before you arrive for your appointment or walk-in...
​

1) Please read the ELIGIBILITY page on our website
2) Collect the documents needed for your eligibility screening
3) Fill our our patient forms below to prepare for your visit 

We look forward to serving you! 


Welcome Letter
CARTA - BIENVENIDOS A LA CLINICA
Privacy Practices
AVISOS de PRIVACIDAD
Release of Information Form

BLANK ELIGIBILITY FORMS YOU MAY NEED

Below are blank forms that may apply to you as a patient.
​Please speak with the clinic to start the process. 
Cash Income Statement
Declaracion De Ingresos Ganados En Efectivo
Income - Expense Ledger
Registro de Contabilidad
Letter of Support
Carta De Apoyo
Verification of Employment
Verificacion De Empleo
 35 Rock Pointe Lane, Warrenton VA 20186   I  540-347-0394   FAX 540-349-3262
​
The Fauquier Free Clinic is a registered 501(c)(3) Nonprofit organization   I    EIN # 54-1669652
  • Home
  • Patients
    • Services
    • Eligibility
    • Patient Forms
  • Volunteer
  • Donate
  • News & Events
    • Charity Golf Tournament
    • Give Local Piedmont
    • Rappahannock Rough Ride
    • Expanded Care Plan
  • About Us
    • VHCF Dental Expansion Report
    • Strategic Plan
    • Meet Our Dental Team
    • Contact Us
    • Hours & Location
    • History
    • 2025 Annual Report
    • 2024 Annual Report
    • 2023 Annual Report