Intake Form

Intake Form
Welcome to Fusco Care

We proudly serve New York’s dedicated public service community - including school staff, faculty, teachers, police officers, and other essential workers. Thank you for all that you do.

If you’re interested in medical massage therapy and require a referral, we offer convenient telemedicine appointments online to help you get started with the referral process quickly and easily.

Please complete the intake form below, and our team will follow up with you regarding insurance coverage and scheduling your appointment.

We look forward to supporting your health and wellness.
Patient Information
Patient Name

First NameLast Name
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Date of Birth

MonthDayYear
Date
Patient Email
example@example.com
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Gender
How did you hear about Fusco Care / who referred you?
Which service(s) are you interested in?

Other
Are you interested in Telemedicine or In-Person Appointments?
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation To The Patient
Insurance Information
If you have your insurance card accessible, please upload a picture of the front.

Cancelof
Primary Insurance
Insurance Company
Member ID
Group Number
Insurance Phone Number
Insurance Company Address
Person Responsible for the account

First NameLast Name
Relationship to account holder (if yourself, write "self")
Date of Birth of the account holder

MonthDayYear
Date
Gender of account holder
If you have your insurance card accessible, please upload a picture of the front.

Cancelof
Do you have secondary insurance?
Secondary Insurance
Secondary Insurance Company
Member ID
Group Number
Insurance Company Address
Insurance Phone Number
Person responsible for the account

First NameLast Name
Relationship to account holder (If it is yourself, write "N/A")
DOB of the account holder

MonthDayYear
Date
Gender of the account holder
Medical Information
Are you taking any medications currently?
If yes, please list them and the dosage.
Have you ever, or do you currently smoke or use Tobacco products?
What is the primary reason for your appointment?
Do you have a medical history of any of the following?

Other
If other, please list here
Do you have any allergies? If yes, list them here
If you are looking to do labwork, do you have a lab preference?
By checking here, you consent to receive periodic email updates from Fusco Care, including new services or treatments being offered, insurance updates, and promotional content.
By signing below, I agree that all the information above is true.
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Intake Form

Patient Information

Emergency Contact

Insurance Information

Primary Insurance

Secondary Insurance

Medical Information