Language
English (US)
Patient's name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Daytime Phone Number
*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Patient's Date of Birth
*
-
Month
-
Day
Year
Date of Birth
Primary Insurance Holder’s Name
First Name
Last Name
Primary Insurance Holder Date of Birth
-
Month
-
Day
Year
Date
Insurance Name
Insurance Address (found on the back of your card)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone Number (found on the back of your card)
Please enter a valid phone number.
ID Number
Subscriber name
First Name
Last Name
Employer name
Emergency Contact
Emergency contact name
*
First Name
Last Name
Emergency contact phone number
*
Please enter a valid phone number.
Emergency contact address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency contact email address
*
example@example.com
If you were referred to the TRAINOR Center, please provide referral name and contact information below:
Referral Name
First Name
Last Name
Referral Phone Number
Please enter a valid phone number.
I GRANT DR. TRAINOR AND THE TRAINOR THERAPISTS PERMISSION TO BILL MY INSURANCE PROVIDER FOR SERVICES. I AGREE TO PAY THE BALANCE THAT INSURANCE DOES NOT COVER. I AGREE TO GIVE 24 HOURS’ NOTICE FOR ANY CANCELLED APPOINTMENTS OR I WILL PAY FOR THE FULL SESSION FEE.
*
I agree
Telehealth
*
I AGREE TO RECEIVE TELEHEALTH SERVICES.
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