Patient Registration | Volunteers In Medicine

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PATIENT REGISTRATION

CVVIM is NOT an Urgent Care Clinic. If you have a MEDICAL EMERGENCY, CALL 911 or visit an Emergency facility in your area.
We provide Primary Medical Care only. We do not provide Dental Services at this time.

Patient Information

Today's Date *

Why do you need to see a doctor? *

Name *

First

Last

Email *

Confirm Email

Birth Date *

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Homeless

Homeless

Phone (Primary Phone) *

Is this a CELL phone?

Gender *

Photo ID (check one) *

Driver's License
State ID
Passport
Native Tribal Card

Proof of Residency *

Gas Bill
Electric Bill
Telephone Bill
Property Tax Statement
Other Utility Bill w/Home Address
Homeless (No Proof Required)

Race | Ethnicity *

African American
Hispanic / Latino
White (Caucasian)
Other

Other Race | Ethnicity

Primary Language Spoken *

English
Spanish
Other

Other Language Spoken:

Primary Language Read *

English
Spanish
Other

Other Language Read:

Who do we contact in case of an EMERGENCY? *

First

Last

Phone (Emergency Contact) *

Relationship: *

Employment Information

Are you currently employed? *

In what city do you work?

Class of work (select one): *

Construction
Agriculture | Farmer
Landscaper | Gardner
Hotel | Motel
Maintenance | Janitor
Restaurant | Food Service
Healthcare | Homecare
Other

Employment Status (select one): *

Unemployed
Employed - Part Time
Employed - Full Time
Seasonal
Retired
Disabled
Self-Employed
Student

Have you been to the Emergency Room as a patient within the past 6 months? *

If YES, how many visits to the Emergency Room have you made in the past year? *

If YES, which hospital's Emergency Room did you visit? (select one) *

Eisenhower Medical Center (Rancho Mirage)
JFK memorial Hospital (Indio)
Desert Regional Medical Center (Palm Springs)
Riverside County Regional Medical Center (Moreno Valley)
I have not been to the Emergency Room as a patient within the past 6 months

Who referred you to CVVIM? *

How did you get to CVVIM? (select one): *

Bus
Car
Friend or Family Member
Other

Are you currently experiencing any of the following: *

Food
Housing
Transportation
Paying my bills
Other

Please briefly describe the area where you need help.

(e.g., affording groceries, regular meals)

(e.g., finding a stable place to live, paying rent)

(e.g., getting to appointments or work)

(e.g., paying for electricity, heat, or gas)

Household Size & Income Verification

Number of people in your (PATIENT's) Household | Annual Income Requirements (select one):

1: $46,950 Family income cannot exceed this amount.

2: $63,450 Family income cannot exceed this amount.

3: $79,950 Family income cannot exceed this amount.

4: $96,450 Family income cannot exceed this amount.

5: $112,950 Family income cannot exceed this amount.

6: $129,450 Family income cannot exceed this amount.

7: $145,950 Family income cannot exceed this amount.

8: $162,450 Family income cannot exceed this amount.

9+: Add $16,500 for each additional person.

Proof of Income (select one): *

Are you paid in cash? *

Verification

Please review your form to be sure all questions have been answered.
Click SUBMIT to send your form.

DO NOT COMPLETE THIS SECTION. CVVIM STAFF OR VOLUNTEER ONLY.

Volunteer Name

🔒 Your Privacy Matters
We keep all your information strictly confidential and secure. Sharing your needs helps us connect you wth the right free resources and medical care. We will never share your details without your permission.