Touch Therapy Associates

Office: 30095 Northwestern Highway, Suite 40 A, Farmington Hills, MI 48334

PATIENT INFORMATION FORM

Patient's Name:
Daytime Phone include area code:
Evening Phone include area code:
Email Address:
Auto Insurance Company:
Claim Representative:
Claim Rep's Phone include area code:
Claim or Case #:
Date of Injury mm/dd/yy:
Patient's Date Of Birth mm/dd/yy:
Name of Insured (if other than patient):
Relation to insured:
If Auto Insurance is not primary, name of Health Insurance Co.:
Have you spoken to your Physician about massage therapy?:		yes no
Physicians Name:
Physician's Phone include area code:
May we contact your Physician on your behalf?:		yes no

Privacy Statement
Touch Therapy Associates, Inc. respects the privacy of every person who visits this website. Any personal information collected from our visitors will remain strictly confidential with Touch Therapy Associates, Inc.

30095 Northwestern Highway, Suite 40 A, Farmington Hills, MI 48334 - Phone: 248-626-6277

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