Intake Forms

Please print, complete, and bring the health intake form to your first appointment.

If you wish to bill insurance, please complete the following insurance form to verify benefits in advance of your first appointment:

Insurance Form to Verify Benefits

Name

First Name

Last Name

Date of birth

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Insurance company name

Member ID

Group number

Insurance company contact number (on back of card)

Name of insured (if other than yourself)

Please print, complete, and bring the insurance intake form to your first appointment.