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.

Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY
Date of Birth*
Date Format: MM slash DD slash YYYY
Phone*
Email*
Address*
Street Address City State ZIP Code
Name of Parent/Guardian (if applicable)
Family Size*
Upload Proof of Income documents*
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 Worksheet*
Income Source Income Recipient's Name Income 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.
Total income for all household members*
Sum of all the income sources listed above
TOTAL income reported is:*

Financial Hardship Application

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Income Source	Income Recipient's Name	Income amount