New Client Info. Request

New Client Info. Request Form

Information obtained are stored using HIPAA standards.
1 - Personal Info.
Date*

MonthDayYear
Date
Client Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Age
Height*
Weight*
Gender*
Pets?

6 - Long Term Care Insurance

We are approved by LTC Insurance companies. If you have a policy, please let us know. We can help you file claims. If none, please move to section 7.
Does the patient have Long Term Care Policy? If none, please skip to section 6.A

YesNoUnsurePrefer not to say
If YES, please indicate LTC company
Policy#
Claim# (if any)
Last 4 digits of SSN
LTC Info/ Instructions

7 - Legal Representation
Legal Representative Name - if something happens to you.*

First NameLast Name
Representative Role (select all that applies)*

SelfPower of attorney (POA)Healthcare DirectiveConservatorOthers
Relation*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Legal Representative Phone#*
Please enter a valid phone number.
Legal Representative Email*
example@example.com
In case Patient is unavailable to make payments, Legal Representative will handle all payments.*

YesNo
Other information/ instructions about Legal Representation

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I certify the above information are true and correct. *

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Client/ Representative
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