NaturalHealth Choice®
   
Natural forces within us are the true healers
--Hippocrates

INSURANCE
INFORMATION

 
  Patient  
* Name (first, last) / Gender:     
* Date of Birth:       
* Address:       
* City, State, Zip:      
* Phone:      
* eMail:        
  Insurer  
* Subscriber No / Member ID No:     
* Group / Acount No:      
* Insured Name & ID / Relationship:     
* Insurance Company Name:      
* Insurance Company Phone:   (for providers)  
Claim No (if an accident):    
Date of Accident / Injury:    
Other Info:   

     


 
Insurance Form




PREPARE FOR
YOUR VISIT
PRACTICE
1209 NW 12th Avenue
Gainesville, FL 32601

 
   Mon: 3pm - 7pm
Tue-Fri: 9am - 7pm
Sat: 9am - 1pm

  
call for appointment:
(352) 378-8002
  
www.naturalhealth-choice.com
Serving Gainesville | Alachua | Newberry | Archer | Micanopy | Hasan | La Crosse | Waldo | Rochelle | Hawthorne | Traxler | Melrose | High Springs | McIntosh | Ocala | The Villages | Citra
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