WEDNESDAY FREE CLINIC

It is hard to take care of the medical needs of your child when you do not have insurance coverage. Healthcare is expensive!

If your child does not have health insurance, we can see you for free in Dr. Miniyar’s Free Wednesday Clinic from 2:00 to 4:30 pm at our Rome location. Please read carefully the rules, terms, and conditions of our free clinic.

We are a 100% private practice. We do not receive any funds from the government or any other organization like most free medical facilities do when they see uninsured children. We solely take care of the cost related to this free clinic. We are aware of our limitations and know that our free clinic may not make a huge impact on the much larger and complex problem related to the healthcare of uninsured children. However this is just a small effort on our part to make a difference.

If your child needs to be seen in our free clinic, please complete the following information and a member of our staff will call you to confirm the appointment.

Your First Name:

Last Name:

Relationship to Patient:

Cell Phone number:

Email:

Child's First Name:

Child's Last Name:

Age:

Reason why your child needs to be seen:

Please check each box below to show you agree with the terms and conditions of our free clinic:

I certify that the following information is 100 % true and accurate.

I certify that the above mentioned child does not have any form of health insurance whatsoever (Medicaid/CMO/Private). I understand and agree that the free clinic is exclusively for patients who do not have any health insurance coverage of any kind.

I understand and agree that, only medical care provided by Dr.Miniyar's Pediatrics, P.C. in their Rome office will be free. I will be responsible for cost/charges from pharmacy, labs, hospital, outside other medical facilities etc. Dr. Miniyar's Pediatrics does not have any control over that.

I understand and agree that no controlled substances or pain medication will be prescribed at the free clinic visit.

I understand and agree that the free clinic only operates during the above designated hours. I am required to make an appointment to be seen specifically in the free clinic and I cannot walk in.

I understand and agree that If I am seen out side the designated free clinic hours, I am responsible for the payment as per the payment policies of Dr. Miniyar's Pediatrics, P.C.

I understand and agree that the free clinic is only for Pediatric patients (Birth to 18 years of age)