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PATIENT REGISTRATION
NOTICE:
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
The terms of our Eligibility Requirements do not permit us to accept applicants that reside outside of the Coachella Valley.
Enter your mailing address (if different from your Street Address)

 EMPLOYMENT INFORMATION

 HOUSEHOLD SIZE & INCOME VERIFICATION


 ADDITIONAL INFORMATION

 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.