Therapy Request Form

Please enter as much information as possible and we will contact you shortly. To learn more about who qualifies and how it works please click here

Full Name
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Phone Number
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Email
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Insured name (if different)
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Date of birth (Format: yyyy-mm-dd)
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Insurance Company/Agency
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Claim number
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Date of accident (loss) (Format: yyyy-mm-dd)
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Insurance adjusters name (if available)
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Insurance adjusters phone number (if available)
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Do you have a current prescription for massage therapy?
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Prescribing physician's name and specialty (if applicable)
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Please briefly describe the type and duration of any physical medicine services, if any, that you've already received for this injury. You can also provide any other relevant information about your claim or injury here.
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Security Check

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