Cancel payment
Acupuncture Restorative Center
Choose clinic location
Acupuncture Restorative Center
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
Acupuncture (Existing Patient)
Acupuncture (New Patient)
Duration:
minutes
Choose a provider
Select the practitioner or skip this step if you do not have a preference
Choose practitioner
Rasa Sammy
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
Sat
, Feb 22
No availabilities found on this day.
Sun
, Feb 23
No availabilities found on this day.
Mon
, Feb 24
No availabilities found on this day.
Tue
, Feb 25
No availabilities found on this day.
Wed
, Feb 26
No availabilities found on this day.
Thu
, Feb 27
No availabilities found on this day.
Fri
, Feb 28
No availabilities found on this day.
Sat
, Feb 29
No availabilities found on this day.
Insurance verification
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
Auto Accident?
No-Fault / Personal Injury
Choose
Yes
No
Date of accident
Please bring your authorization form to the office
Case/Claim #
Case Manager's Name
Case Manager's Phone #
Address to submit claims
Employment Accident?
Workers Compensation
Choose
Yes
No
Date of injury
Please bring your authorization form to the office
Case/Claim #
Employers Name
Employers Address
Insurance company name
Insurance company phone
Insurance company address
I have read and accept the
Terms of Use
and
Privacy Policy
Please read and accept the user agreement.
