By submitting this form, I understand that my personal information will be used ONLY for the insurance verification process. It will be accessible to Living Room Acupuncture and to a third-party biller.  All of our client information is confidential.  We do not share or sell any of or client information.

First and Last Name (required)

Your Email (required)

Address (required)

City, State and Zip Code (required)

Your Telephone Number (required)

Your Birthdate (required)

Your Insurance Company (required)

Your Subscriber ID/Policy Number (required)

Group# (required)

Insurance Company Telephone (required)

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