Fauquier Free Clinic
  • Home
  • Patients
    • Services
    • Eligibility
    • Patient Forms
  • Volunteer
  • Donate
  • News & Events
    • Charity Golf Tournament
    • Rappahannock Rough Ride
    • Give Local Piedmont
    • Expanded Care Plan
  • About Us
    • Contact Us
    • Hours & Location
    • History
    • 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! 


Patient Welcome Letter
Patient ROI Form
Notice of Privacy

Blank Forms in English

Below are blank forms that may apply to you as a patient.
​Please speak with the clinic to start the process. 
Cash Income Statement
Income - Expense Ledger
Letter of Support
Verification of Employment

Formularios en Blanco en Español

A continuación, encontrará formularios en blanco que podrían serle aplicables como paciente. Por favor, comuníquese con la clínica para iniciar el proceso.
Declaracion De Ingresos Ganados En Efectivo
Registro de Contabilidad
Carta De Apoyo
Verificacion De Empleo
 35 Rock Pointe Lane, Warrenton VA 20186   I  540-347-0394   FAX 540-349-3262
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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
    • Rappahannock Rough Ride
    • Give Local Piedmont
    • Expanded Care Plan
  • About Us
    • Contact Us
    • Hours & Location
    • History
    • 2024 Annual Report
    • 2023 Annual Report