Healing Arts Center Intake Packet

Patient Type(Required)

Service Type(s)(Required)

Acupuncture

Massage

First Name(Required)

Last Name(Required)

Email(Required)

New Patient Information

First Name(Required)

Last Name(Required)

Email(Required)

Date of Birth(Required)

Social Security(Required)

Sex(Required)

Race

Other

Ethnicity

Primary Language(Required)

Primary Phone

Secondary Phone

Work

Address(Required)

Street Address Address Line 2 City State ZIP Code

Referring Physician(Required)

Phone

Primary Care Physician(Required)

Phone

Primary Insurance Information

Name of Insurance Company

Policy Number

Are you the policy holder

Name of Policy Holder

First Last

Relationship to Patient

Date of Birth

Social Security

Phone

Address

Street Address Address Line 2 City State ZIP Code

Employer

Secondary Insurance Information

Do you have a secondary insurance policy

Name of Insurance Company

Policy Number

Group Number

Are you the policy holder

Name of Policy Holder

First Last

Relationship to Patient

Date of Birth

Social Security

Phone

Address

Street Address Address Line 2 City State ZIP Code

Employer

Work / Auto Related Injury

Is this the result of an accident

Date of Injury/Accident:

Insurance Carrier

Contact Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Claim Number

Insurance ID Number

State where injury occurred

Employer Name

Employer Address

Street Address Address Line 2 City State ZIP Code

Contact Name

First Last

Phone

Address where injury occurred

Job Title

Job Duties

Adjuster Handling Claim Name

First Last

Adjuster Handling Claim Phone

Attorney Handling Claim Name

First Last

Attorney Handling Claim Phone

Healing Arts Center Intake Packet