Enroll In Food As Medicine

Please fill out form below.

Healthy Foods

Enrollment in this produce delivery service does not show as a public charge and will not affect any government aid, status, or current services you are receiving.

Food As Medicine Enrollment

Patient First Name

Patient Last Name

Phone/Mobile

Address Line 1

Address Line 2

City

State

Zip Code

Country

Gate Code

Which Clinic were you referred by?

Delivery or Pick up Preference

Delivery

Pick up

^* You are not required to be home for deliveries, we will leave the produce.

Pick Up

Tuesday noon to 3 PM

Wednesday noon to 3 PM

Thursday noon to 3 PM

Not sure but will stop by

Delivery Notes

Are there any special delivery instructions needed for your place of residence? If no, leave blank.

Dietary Issues

Select all that apply

# Children in Household (0-17)

# Adults in Household (18-26)

# Adults in Household (27-59)

# Adults in Household (60+)

Do you or a family member qualify for public assistance?

Select all that apply

Race/ethnicity of all household members

You can select multiple

Does your household fall into any of these categories?

You can select multiple

Household Income

Are you an OSW staff member?

OSW projected start date

What agency is completing this form?

Dig Deep Farms is working with researchers from Stanford University to conduct surveys with Food Farmacy participants. Patients will be surveyed twice – before the first delivery and at week 12 of the program. Patients who complete both baseline and follow-up surveys may receive a total of $50 (paid via e-gift card). Do we have your permission to share your contact information with Stanford researchers?

Do you give consent to receive text messages from Dig Deep Farms?

Do you have a Referral ID? (For Staff Only)

Referral ID

Enroll In Food As Medicine

Healthy Foods

Location