Insurance Screening Form Please fill out this form completely and we will get in touch with you If you are a human and are seeing this field, please leave it blank. * Required field Patient's Name * First Name * Last Name * Email Address * Patient's Address Street Address City State Zip / Post Code Patient's Primary Phone * Patient's Date of Birth * Name of Policy Holder Relationship to Patient Policy Holder Employee Policy Holder Date of Birth Insurance Company Insurance Phone Number Policy ID Number Group ID Number Do you have a secondary insurance policy? * Secondary Insurance Policy YesNo If yes, list the insurance company name: