Chesapeake Care Clinic
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O N L I N E   A P P L I C A T I O N

    PATIENT INFORMATION FORM


    PERSONAL  INFORMATION

    Emergency Contact

    EMPLOYMENT

    INSURANCE  INFORMATION
    Medical Insurance Information

    Dental Insurance Information

    OTHER INFORMATION

    DOCUMENTS TO UPLOAD
    Max file size: 20MB
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    PLEASE UPLOAD ALL OF THE FOLLOWING DOCUMENTS THAT APPLY TO YOU:
    Business Taxes for the Most Recent Tax Year
    Latest Quarterly Filing
    90 Days of Business Bank Statements
    Business Profit/Loss Statement for Current Year 
    60 Days of Most Recent Pay Stubs 
    ​Social Security or Supplement Security Income Award Letter
    Veteran Benefits Award Letter
    Pension or Retirement Award Letter or Statement
    Unemployment Award Letter
    Verification of Alimony

    Verification of Child Support
    ​Workers Compensation Award Letter
    SNAP Letter
    TANF or Transitional TANF Assistance 
    Housing Assistance Letter
    Owned Rental or Investment Property Documentation
    Stocks, Bonds, CDs, 401K Statements
    90 Days of Most Recent Bank Statements for each Account Owned
    Verification of Support Form
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB

    CONSENT *
    By checking the boxes below I agree to comply with the terms of eligibility as set forth & outlined by Chesapeake Care Clinic in these statements.

Submit
CHESAPEAKE  CARE  CLINIC
2145 S. Military Highway Chesapeake, Virginia 23320
(757) 545-5700
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  • HOME
  • OUR CLINIC
    • About Us
    • Board of Directors >
      • Board Access
    • Patient Testimonies
    • Contributors
    • Videos
  • DONATE
    • Give Now
    • Donations
  • PATIENTS
    • New Patients
    • Services
    • Veterans Dental Program
    • Mini-Mission of Mercy
    • Eligibility Criteria
    • Online Application
    • Upload Documents
    • Online Payment
    • Privacy Practices
  • VOLUNTEER
    • Volunteer Opportunities
    • Volunteer Application
  • FUNDRAISERS
    • Wine Tasting
    • Taste of Chesapeake
    • Run For the Health of It
  • NEWS & RESOURCES
    • COVID-19
    • Annual Report
    • Newsletter Sign Up
    • Newsletter Archive
    • Facebook
  • CONTACT US
    • Contact Us
    • Hours of Operation
    • Location