Clinic with a Heart Patient Forms

Patient Forms

Once you have an appointment, click on the links below to complete your patient information.
Use this link if your appointment is for Medical, Dental, Chiropractic or Mental Health
Use this form if your appointment is for a School and Sports Physical.

Clinic with a Heart is a Free Healthcare Clinic

We do not diagnose or treat Covid-19. We also do not write notes related to Covid-19 and we will not write a note exempting you from wearing a mask.

We do not require patient identification or proof of income.

Call in on clinic days, after 2:00 p.m., to reserve a spot. Our number is 402-421-2924. At that time you will be given a number and return time (or told that we are full). You may NOT leave a voicemail message to reserve a spot. You must talk to someone at Clinic with a Heart.