p: (337) 504-5144
f: (337) 326-4545
Need Relief?
Headaches
Neck Pain
Back Pain
Joint Pain
Nerve Pain
Cancer Pain
TMJ Pain
Performance
Pain Proof Wellness Program
Running Clinic
GB2BG
Orthopedic Rehab
Athletes
Weight Management
Cryotherapy
H.E.R.O. Recovery System
Float
Float FAQ
Schedule Your Float
New Patient
Success
About Us
Staff
Location
Insurances Accepted
Contact
Media
Blog
Video Library
>
Cervical (Neck)
Schedule Your Float
Product
REGISTRATION
Patient Registration
*
Indicates required field
Name
*
First
Last
Date of Birth
*
Email
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Patient under the age of 18?
*
Yes
No
Medical Insurance Information
Please fill out insurance information including Insurance Name, Policy number, group ID and Insurance Telephone number. Bring all insurance cards to your appointment. You may upload a copy of your insurance card as well.
Copy of Insurance Card
*
Max file size: 20MB
Date of Birth
*
Social Security Number
*
Insurance Company
*
Policy Number
*
Group ID
*
Insurance Phone Number
*
Additional Insurance Information
*
Medical Information
Referring Physician or Primary Care Doctor
*
Reason for visit
*
Current Medical History
*
Surgeries
*
Have you been diagnosed with?
*
Tuberculosis
Heart Condition
Pacemaker
Cancer
Hepatitis
Diabetes
Stroke/CVA
Respiratory Problems
Bleeding Disorder
Epilepsy
Medications
*
Previous Treatment
*
Submit
