TAMA Free Clinic — Patient Registration

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Select Your Service(s)

What service(s) do you need? *

🩺

Medical Clinic

In-person visit

🦷

Dental

In-person visit

📱

Tele-Dental

Virtual consultation

You can select more than one service

Please select at least one service

Patient Information

First Name *

Please enter first name

Last Name *

Please enter last name

Representative / Emergency Contact

Rep. First Name *

Please enter representative first name

Rep. Last Name *

Please enter representative last name

Contact Details

Contact Number *

Please enter a phone number

Contact Email *

Please enter a valid email

Medical Information

Are you currently on any medication? *

Yes No

Please select Yes or No

Issue Details / Current Medications

Select Visit Date

Which Wednesday? *

Please select a clinic date

Please note: Report between 7:00 PM – 7:30 PM. Please bring current medications and any medical reports to your visit.

Consent

TAMA Free Clinic — Patient Consent

I understand that the TAMA Free Clinic provides free community health services staffed by volunteer healthcare professionals. I consent to receive the selected medical or dental services. I understand that this clinic does not replace regular primary care and is intended for community health support. I agree to provide accurate health information to ensure safe and effective care. My personal and health information will be kept confidential and used only for the purpose of providing clinic services and follow-up communication.

I have read and agree to the patient consent above. *

🔒 Your information is confidential and used only for clinic scheduling purposes.

TAMA Free Clinic Registration

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