Sliding Scale Form Please enable JavaScript in your browser to complete this form.First Name *Last Name *Email *Date of Birth *MONTHLY BUDGETIf you will not be using insurance, please complete the below Monthly Budget Information so that we can determine your Sliding Scale Fee. You must also upload proof of income documentation:FAMILY INFORMATIONApplicant’s Gross Monthly Income $Applicant’s Other Monthly Income (e.g, social security, alimony, pension) $Spouse’s NameSpouse’s Gross Monthly Income $Spouse’s Other Monthly Income (e.g, social security, alimony, pension) $TOTAL MONTHLY INCOME: $MONTHLY HOUSEHOLD & LIVING EXPENSESRent/ Mortgage $Utilities $Groceries/Food $Transportation $Healthcare $Child Care/ Babysitting $Alimony/ Child Support $Loan Payment $Credit Card $Other: $TOTAL MONTHLY EXPENSES $Additional ExpensesList any other bills not listed, and specify frequency (monthly, weekly, etc.)Signature of Patient *Date *Upload proof of income documents (e.g. pay stubs, tax documents) Click or drag files to this area to upload. You can upload up to 4 files. PhoneSubmit