Patient Intake — Insurance Submission

First Name First name is required.

Last Name Last name is required.

Date of Birth Date of birth is required and cannot be in the future.

Insurance Card (PDF)

📄

Click to upload or drag & drop
PDF files only

📎

Please upload a valid PDF insurance card.

BACK OF INSURANCE CARD (OPTIONAL)

📄

Click to upload or drag & drop
PDF files only (optional)

📎

Please upload a valid PDF file.

Does the patient have a secondary insurance?

Please indicate if the patient has secondary insurance.

Company

Please select a company.

Treatment

Please select a treatment.

✅

Submission Received

The patient's information has been submitted successfully and a profile has been created for staff review.

⚠️

Something went wrong while submitting this patient. Your information has been preserved — please try again.