Acupuncture | Baltimore | Acupuncture & Wellness Center

Restore Balance To Your Life & Body

Claims Office Address

Insured's name: *

Home Phone:

Plan Name

STEP 2:
Once we verify your insurance (and before you come in for your appointment), please download and complete the Intake, Consent, & Office Policies Form. Please bring completed documents and your insurance card with you to your Initial Visit.

Questions or concerns? Call the office at (443) 219-1220

Acupuncture Intake Form

Address (Street, City, State, Zip) *

Date of Birth *

Group # *

New Patient

Cell Phone: *

AWC Office Policies

Patient Name (First, Last): *

Insurance Company *

Consent Form

Member ID *

Email: *

Insurance Company Phone *

Please make sure to complete ALL sections with an * in order for the form to be submitted correctly. You will be prompted if a section is not completed. If all sections are completed correctly, the SUBMIT button will turn a bright blue and allow you to click submit. Thanks!

Gender Identity

How did you find us? *

Insured's date of birth: *

STEP 1:
Please fill out the form to below and click Submit. We will contact you as soon as possible with the quoted coverage from your insurance company and to schedule your Initial Visit.

If you are a new patient to Acupuncture & Wellness Center and are looking to book an acupuncture appointment, please call 443.219.1220 or email donnadegnanlac@gmail.com. We will be happy to speak with you about setting up an appointment, discussing any needed paperwork, and completing a courtesy insurance verification to find out if your plan carries any acupuncture therapy benefits.

Acupuncture Appointment

Initial reason for visit (ex: headaches, back pain, infertility, etc...) *

Sex assigned at birth:

Male

Female

Intersex

if you selected other or were referred by another patient, please specify

Acupuncture | Baltimore | Acupuncture & Wellness Center

Restore Balance ​To Your Life & Body

New Patient

Restore Balance To Your Life & Body