Cancel payment
Evolve Health + Wellness
Telemedicine appointments are now available at
Evolve Health + Wellness
Choose clinic location
Evolve Health + Wellness
Appointment details
Are you a new or existing patient at this clinic
New patient
Existing patient
Choose a service
Services are specific to each office
Choose a service
Virtual Visit
Duration:
minutes
Choose a provider
Select the practitioner or skip this step if you do not have a preference
I don't have a preference
Christina Ippolito
Frank Butler
Jen Resnick
Nini Mai
Xin Tao
Reason for visit
Patient name
Date of birth
Gender
Select Gender
Male
Female
Other
Other Gender
Email address
Phone number
Cell
Home
Work
Other
Cell
Home
Work
Other
How did you hear about us?
Available times
Prev week
No availabilities found. Please try another week.
Next week
Sun
, Apr 5
No availabilities found on this day.
Mon
, Apr 6
No availabilities found on this day.
Tue
, Apr 7
No availabilities found on this day.
Wed
, Apr 8
No availabilities found on this day.
Thu
, Apr 9
No availabilities found on this day.
Fri
, Apr 10
No availabilities found on this day.
Sat
, Apr 11
No availabilities found on this day.
Insurance verification
Insurance Information
If you have an insurance policy that covers acupuncture, or have insurance but are unsure whether acupuncture is covered, and would like to use your coverage for your visits, please provide us with your insurance information.
If you want to use insurance for your visit please fill out the fields below so that we can verify your coverage
Choose
yes
no
Name of Primary Insurance
(Blue Cross, Aetna, Anthem etc.)
Insurance Type
(HMO, PPO etc.)
ID # on insurance card
The ID number on your insurance card
Group number
Insurance Provider Phone Number
Located on back of insurance card
Claim address
Located on the back of insurance card
City
ZipCode
State
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Covered under someone else's insurance plan?
Select "yes" if you are covered under someone else's insurance
Choose
Yes
No
Patient relationship to insured
Select relationship to insured
Spouse
Child
Other
First Name of Insured Party
First Name of the primary policy holder
Middle Name of Insured Party
Middle Name of the primary policy holder
Last Name of Insured Party
Last Name of the primary policy holder
Insured Party Date of Birth
Date of birth of the primary policy holder
I have read and accept the
Terms of Use
and
Privacy Policy
Please read and accept the user agreement.
