INSURANCE?

WE'LL BE GLAD TO CONFIRM YOUR ACUPUNCTURE COVERAGE.

SIMPLY FILL OUT THE CONFIDENTIAL FORM BELOW AND WE'LL

GET BACK TO YOU WITHIN ONE-TO-TWO WORKING DAYS.

THANK YOU.

NAME (FIRST AND LAST)

DATE OF BIRTH

ADDRESS

PHONE

INSURANCE PLAN NAME

GROUP NUMBER

INDIVIDUAL NUMBER

"PROVIDER" CONTACT NUMBER

IF YOUR SPOUSE/PARTNER IS THE PRIMARY MEMBER, PLEASE

SUPPLY THEIR NAME & DOB:

OTHER NUMBERS/CODES ON CARD

OTHER INFORMAION:

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