Client Reactivation/Update

Client Reactivation / Update

Complete the following sections:
Section 1: Personal Information

Section 2: Contact Information & Privacy Permissions

Section 3:Insurance
TODAY'S DATE:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The following workflow will be completed:

Rows	Full Name	Relationship	Contact Info	Are they aware of your status?
Emergency Contact:

Rows	Phone	Voicemail	Text
No
Yes

Rows	Mail	Email	Work
No
Yes

Rows	No	Yes
Health insurance
Additional Prescription Insurance
Dental or Vision Insurance

Client Reactivation / Update