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  • English (US)
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  • Thank you for your interest in becoming a client of GoochlandCares.

    Our online application process consists of three parts. Each of the three parts of the application must be submitted for your application to be processed by a registration coordinator. This is a protected process and your submissions will be held confidentially. 

      (1) UNIVERSAL REGISTRATION 
      (2) SUPPLEMENTAL HOUSEHOLD MEMBERS
      (3) CONSENT AGREEMENTS


    Please click NEXT to begin.

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  • General Patient Information

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  • Emergency Contact Details

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  • Demographic Details


  • Household Information

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  • Employment Information

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  • Insurance Information

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  • Income Information
    For the following section, please list the amount of income, before taxes, earned by ALL PERSONS in the family unit. Include the following types of income: wages/salary/self-employment, child support/alimony, interest/dividends, disability benefits, retirement benefits, Social Security Income, Unemployment benefits, and any other type of income. Do not include income from loans.

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  • I, {fullName}, certify that the information herein is an accurate to the best of my knowledge. I understand that the information is subject to verification. I understand that if my financial situation changes or I obtain health insurance, my eligibility status will need to be re-evaluated. I understand it is my responsibility to notify THE CLINIC of any changes in my financial situation. I authorize the release of my financial records (including Social Security Number) to RX Partnership, pharmaceutical companies and Access Now and/or their agents to determine my eligibility for financial assistance for medicines and verification during routine audits. This review is a check on eligibility only. It is not a guarantee that I will receive benefits from any source, and THE CLINIC offers no such guarantees. I understand that falsification of information submitted will jeopardize my consideration for the program.

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