First Name *

Last Name *

Date of birth

Email *

Street Address

City

State

Country

Postal code

Phone

Insurance Company *

Member ID *

Group Number *

Insurance Company Phone Number

This is often listed on the back of the insurance card as "Customer Service" or "Provider Line".

Primary Diagnosis or Chief Complaints *

Help us get the most accurate information regarding your benefits by listing your primary diagnosis or your top 3 health complaints you would like treated with acupuncture in the field above.

Additional Information

I consent to receive marketing text messages from Healing Foundations at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

I consent to receive non-marketing text messages from Healing Foundations about my order updates, appointment reminders etc. Message & data rates may apply.