Info Refresh — Great Life Chiropractic & Massage Therapy

Please Refresh Your Information

Thanks for helping us out! We know you’ve been to our office before, but we need you to update your contact and insurance information. Please fill out the following fields so we can best help you at your next appointment.

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Would you like to use insurance?

Yes

Not Sure

With what company is your insurance?

We accept Aetna, Independence Blue Cross, Keystone Health Plan East, All Blue Cross Blue Shield products, along with Medicare and it's associated supplements. If you do not want to use insurance, please enter N/A in the text box.

Please enter your Insurance Subscriber ID:

If you do not want to use insurance, please enter N/A into the text box.

Update us on your condition!

Haven't been to the office in several years? Update us on your current primary complaint, injuries or surgeries you've had, or any other information you think is important for Dr. Ted to know. Keep it short and sweet.