Therapist Name
Clinic Name
Therapist Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Therapist Email
example@example.com
Patient's Full Name
*
First Name
Last Name
Patient Email
*
example@example.com
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Gender
*
Please Select
Male
Female
N/A
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a Primary Care?
Yes
No
Primary Care Physician
Practice Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Physical Therapist Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you aware of having any of the following diagnoses?
Lymphedema
Lipedema
Veinous Insufficiency
Diabetes
Wound(s)
Burn(s)
Other
Upload Your Primary Health Insurance Card
Insurance Carrier Phone Number
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Format: (000) 000-0000.
Front of Card
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of
Back of Card
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I can't upload photos right now.
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I'll fax these to (888) 413-7261
I'll text these to (888) 550-2709
I'll enter the information manually
Insurance Company
Name of Insured
Identification Number
Do you have a secondary insurance provider?
Do you have a secondary insurance provider?
Yes
No
I Don't Know
Insurance Carrier Phone Number
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Format: (000) 000-0000.
File Upload
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of
Back of Card
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of
I can't upload photos right now.
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I'll fax these to (888) 413-7261
I'll text these to (888) 550-2709
I'll enter the information manually
Insurance Company
Name of Insured
Identification Number
Do you have a tertiary insurance provider?
Do you have a tertiary insurance provider?
Yes
No
I Don't Know
Insurance Carrier Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Front of Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back of Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I can't upload photos right now.
No problem. Choose one of these other options:
I'll fax these to (888) 413-7261
I'll text these to (888) 550-2709
I'll enter the information manually
Insurance Company
Name of Insured
Identification Number
What Kinds Of Products Do You Want To Check?
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