Relievus New Patient Appointment Request

RELIEVUS NEW PATIENT APPOINTMENT REQUEST

For insurance policy holders only.
Self pay services please call us.

Relievus Phone: 888-985-2727 Fax: 833-646-2061
Which type of treatment are you requesting to see?
Please select one.
How did you hear about us?
PATIENT NAME*
GENDER
ADDRESS*
CITY, STATE, ZIP*
PATIENT PHONE #

Area CodePhone Number
MOBILE PHONE

Area CodePhone Number
DATE OF BIRTH*

MonthDayYear
Date
SS #
EMAIL ADDRESS
example@example.com
REFERRING PROVIDER
PHONE #

Area CodePhone Number
PRIMARY CARE PROVIDER
PHONE #

Area CodePhone Number
HEALTH INSURANCE INFORMATION

IF YOU DO NOT HAVE HEALTH INSURANCE AND THIS IS A MOTOR VEHICLE ACCIDENT OR WORKERS COMP INJURY, PLEASE PROCEED DOWN TO THE INJURY SECTION.
HEALTH or SECONDARY INSURANCE
ID #
INSURANCE PHONE #

Area CodePhone Number
CLAIMS ADDRESS
SUBSCRIBER NAME
DATE OF BIRTH

MonthDayYear
Date
FOR INJURY CASES ONLY
DIAGNOSIS / INJURED BODY AREAS
PIP/WC CARRIER
DRIVER or PASSENGER
CLAIM #
DATE OF ACCIDENT

MonthDayYear
Date
CLAIMS ADDRESS
POLICY HOLDER
DATE OF BIRTH

MonthDayYear
Date
MVA PIP LIMIT
STATE OF INJURY
ADJUSTER/NCM
PHONE/FAX

Area CodePhone Number
W/C EMPLOYER
ONLY FOR WORKERS COMPENSATION CASES
ATTORNEY
ATTY PHONE #

Area CodePhone Number
ATTY FAX#
REQUESTED PROVIDER
WHICH PROVIDER WOULD YOU LIKE TO SEE? **WE WILL DO OUR BEST TO SCHEDULE YOU WITH YOUR REQUESTED PROVIDER BUT THEY MAY NOT HAVE AVAILABILITY. ***IF NO PREFERENCE IS GIVEN WE WILL SCHEDULE YOU WITH OUR FIRST AVAILABLE PROVIDER.
REQUESTED OFFICE
WHICH OFFICE WOULD YOU LIKE TO BE SEEN IN? IF NO PREFERENCE IS GIVEN, WE WILL SCHEDULE YOU IN THE OFFICE CLOSEST TO YOUR HOME ADDRESS.
Should be Empty:

HEALTH INSURANCE INFORMATION

FOR INJURY CASES ONLY