FREE CLINIC APPLICATION

Applications are available in both English and the Spanish translation. Please upload a color copy of your valid photo ID and any proof of income with your application. If you have income, disregard the final page of the application.

Our staff is happy to provide you with assistance in filling out the application and submitting the required documents without the use of a computer.  Please call 601-286-5551 or stop by the clinic during regular business hours to obtain an application.  Be sure to bring a valid photo ID, social security number and proof of income.