Financial Hardship Application

To apply for consideration, please fill out this form completely. All discounts are based on household annual gross income. Discounts are for office visits only; they do not apply to materials, phone/portal communication (see our regular clinic policies for details), administrative fees, supplements, or other charges.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Drop files here or
    Please include 2 months of paystubs / proof of income OR most recent tax return (2 first pages of 1040 if self employed)
  • Income SourceIncome Recipient's NameIncome amount 
    Include ALL income sources that contribute to the household income. Note: typical hardship discounts are valid for 12 months or until financial circumstances change.
  • Sum of all the income sources listed above