PATIENT FORMS & INFORMATION

NEW PATIENTS

All new patients must fill out and sign the New Patient Forms found below.

New Patient Forms

New Patient Fertility Forms

INSURANCE INSTRUCTIONS AND FORMS

All insurance patients must fill out and sign the New Patient Forms and the Revive Contract with Insurance Patients. These forms must be filled out, signed, and brought to the first acupuncture visit.

Please be aware that to bill insurance for an infertility patient we must address a symptom of pain alongside the infertility issue in order to receive payment from the insurance company. Infertility patients need to fill out the New Patient Forms solely discussing the pain they would like addressed at the time of service. Female infertility patients will additionally fill out the New Patient Fertility Forms.

Insurance patients, depending on their insurance carrier, may be asked to fill out a Pain Management Progress Report every 3rd-6th visit to ensure reimbursement from your insurance company. You can access this form below. Your Revive provider will tell you if and when you need to complete this form.

Revive Contract with Insurance Patients

Pain Management Progress Report