North Dallas Shared Ministries
2875 Merrell Rd
Dallas, TX 75229
214-358-8705

Free Medical Clinic - Patient Information Form

You must have a valid email.

Patient Information

Name(Required)

Sex (M/F):(Required)

Language:(Required)

Date of Birth:(Required)

Address(Required)

Apt #

City(Required)

Zip Code: You must live in our service area. If not you can call 211.(Required)

Telephone # where you can be reached:(Required)

Type of phone:(Required)

Consent to text:(Required)

Can we leave detailed information on the phone listed above?:(Required)

Email Address:(Required)

Race:(Required)

Ethnicity:(Required)

Marital Status:(Required)

Total # of people living in household:(Required)

Combined Monthly Income?$(Required)

Do you have insurance:(Required)

Insurance Name:(Required)

Do You Have Parkland Plan:(Required)

Have you had immunizations here:(Required)

Parent/Legal Guardian Name:

Emergency Contact:(Required)

Emergency Contact Name:(Required)

Phone:(Required)

Cell/Home:(Required)

Household Information

Total # of people living in household:(Required)

List Information regarding ALL OTHER ADULTS Age 18 or over living in your household:

DO NOT LIST YOURSELF BELOW - ANYONE ELSE LIVING AT RESIDENCE SHOULD BE LISTED

Adult 1 First and Last Name

Sex: M/F

Date of Birth:

Relationship to You:

Adult 1 Social Security #

Adult 1 Photo ID #

Adult 2 First and Last Name

Sex: M/F

Date of Birth:

Relationship to You:

Adult 2 Photo ID #

Adult 2 Social Security #

Adult 3 First and Last Name

Sex: M/F

Date of Birth:

Relationship to You:

Adult 3 Photo ID #

Adult 3 Social Security #

Adult 4 First and Last Name

Sex: M/F

Date of Birth:

Relationship to You:

Adult 4 Photo ID #

Adult 4 Social Security #

List Information for ALL CHILDREN under 18 living in your household:

Child 1 First and Last Name

Child 1 Sex M/F

Date

Child 1 Relationship to You

Child 1 Social Security #

Child 2 First and Last Name

Child 2 Sex M/F

Date

Child 2 Relationship to You

Child 2 Social Security #

Child 3 First and Last Name

Child 3 Sex M/F

Date

Child 3 Relationship to You

Child 3 Social Security #

Child 4 First and Last Name

Child 4 Sex M/F

Date

Child 4 Relationship to You

Child 4 Social Security #

Child 5 First and Last Name

Child 5 Sex M/F

Date

Child 5 Relationship to You

Child 5 Social Security #

Child 6 First and Last Name

Child 6 Sex M/F

Date

Child 6 Relationship to You

Child 6 Social Security #

Child 7 First and Last Name

Child 7 Sex M/F

Date

Child 7 Relationship to You

Child 7 Social Security #

How did you hear about our clinic:(Required)

Reason for Visit?(Required)

Medical Clinic requires photo id, proof of address, and previous vaccination records. You can upload documents no or bring them with you to your doctor visit.

Photo ID:

Accepted file types: jpg, jpeg, png, pdf, doc, Max. file size: 100 MB.

Proof of residency (ex. Utility Bill):

Accepted file types: jpg, jpeg, png, pdf, doc, , Max. file size: 100 MB.

Vaccination Records:

Accepted file types: jpg, jpeg, png, pdf, doc, Max. file size: 100 MB.

You will receive a call to schedule your appointment.

By submitting your mobile number, you agree to receive text messages from NDSM. You can opt-out anytime. Message and data rates may apply.
Updated 8.24.2023.

North Dallas Shared Ministries 2875 Merrell Rd Dallas, TX 75229 214-358-8705

Free Medical Clinic - Patient Information Form

Patient Information

Household Information

List Information regarding ALL OTHER ADULTS Age 18 or over living in your household:

List Information for ALL CHILDREN under 18 living in your household:

Medical Clinic requires photo id, proof of address, and previous vaccination records. You can upload documents no or bring them with you to your doctor visit.

You will receive a call to schedule your appointment.

North Dallas Shared Ministries
2875 Merrell Rd
Dallas, TX 75229
214-358-8705