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Appointment Request Form
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HIPAA
Compliance
1
Name
*
This field is required.
First Name
Last Name
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2
Phone Number
*
This field is required.
Please enter a valid phone number.
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3
utm_source
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4
utm_medium
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5
utm_campaign
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6
gclid
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7
Email
*
This field is required.
example@example.com
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8
What is your primary health concern or goal?
*
This field is required.
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9
Do you have health insurance?
YES
NO
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10
Would you like us to verify your insurance coverage and benefits?
YES
NO
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11
How would you like to provide your insurance info
Photograph Card
Upload Photo of Card
Manually Enter
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12
Take Photo of Primary Insurance Card (Front)
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13
Take Photo of Primary Insurance Card (Back)
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14
Upload Primary Insurance Card
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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15
Primary Insurance Carrier
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16
ID Number
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17
If you would like us to verify your coverage Take Photo of Insurance Card (Front)
Please complete if you would like us to complete a complimentary verification of your coverage and benefits
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18
Take Photo of Insurance Card (Back)
Please complete if you would like us to complete a complimentary verification of your coverage and benefits
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19
Date of Birth
Please complete if you would like us to verify your coverage and benefits
-
Month
Day
Year
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20
Preferred Office Location
Midtown East (55th and Madison)
Union Square
Exos Savoy Club at GM Building (exclusively for tenants.)
No Preference
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21
Preferred Appointment Time
/
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22
How did you find out about Complete Wellness?
Referred by a doctor or friend
Google
Instagram
Facebook
Newsletter
Advertisement
Returning Patient
Other - please specify on the next field
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23
Who referred you?
Who should we thank?
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24
How did you find out about Complete Wellness? OTHER
*
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Please specify below:
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25
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