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?
Massage Therapy ReferralLabwork (Quest or Labcorp)Physical ExaminationIV Drip TherapyTrigger Point InjectionsEstablishing CareMedication Refill / ManagmentOther
TelemedicineIn-PersonNot sure
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
YesNo
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
YesNo
If yes, please list them and the dosage.
YesNot currently, but have in pastNo, never
What is the primary reason for your appointment?*
AnemiaHeadaches/MigrainesCancerArthritisDiabetesJoint replacementHeart diseaseHigh blood pressureHeart AttackThyroid disordersStrokeFibromyalgiaKidney dysfunctionBlood clotsHigh cholesterolNone of the aboveDepressionAnxietyNeuropathyOther
If other, please list here
Do you have any allergies? If yes, list them here*
Quest LabLabcorpUnspecified / Other
I accept
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