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We encourage you to download, print, and fill out the following forms and bring them with you to your first appointment.  Thank You!

& Pain Care Center

If you would like us to confirm that your insurance will cover acupuncture before your first visit, please fill out and submit the following form:


Which Insurance company do you have?

What is your Insurance Member ID Number?

What is your birthdate?



What is the phone number from the back of your 
insurance card; Customer Service or Provider 
Services line? 

Name:


Your phone number? 
(You will receive a call you back to let you 
know if your insurance will cover 
acupuncture before your first treatment).

What is your group number?