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Request An Appointment Insurance Intake Form

1800 N. Sepulveda Blvd. #200
Manhattan Beach, CA 90266

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Home
About Us
- Our Approach
- Our Team
What We Do
Specialties
Client Center
Contact
Blog

Insurance

Before your first visit, please submit your insurance info for verification and sign and complete the new client forms. Thank you and we look forward to seeing you at The Wellness Bank.

Your health insurance plan may cover your visits. We can verify your benefits prior to your initial visit so you know your coverage. Please provide the following information:

Insurance Info

Info about insurance

Step 1 of 3

33%

Name
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Insurance*
Name on the Card*
Relation to Subscriber*
- Self
- Spouse
- Child
Subscriber Date of Birth*
MM slash DD slash YYYY

If you chose Child or Spouse above, please enter the Date of Birth of the Primary Subscriber
Marital Status*
Identification#*
Group#*
Insurance Phone Number*
(You can find this number on the back of your insurance card)
Secondary Insurance
Identification #
Secondary Insurance Phone Number

Referring Physician
Diagnosis*
Emergency Contact Name*
Emergency Contact Phone Number*
Which Services Are You Interested In?
- Physical Therapy
- Acupuncture
- Chiropractic
- Redcord
- Pilates
- Therapeutic Yoga
- Fitness Training
- Nutrition
- Massage
- Nutrition
How did you hear about us?*
Person Who Referred You
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Please complete the forms below and bring them with you to your first appointment.

New Client Paperwork Telehealth Consent HIPAA

The Wellness Bank

1800 N. Sepulveda Blvd. #200
Manhattan Beach, CA 90266

Located above the rear entrance of Citizen's Bank

(310) 882-6426
info@thewellnessbank.com

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