Insurance verification form Shannon Russo-Pollack 2017-05-31T21:28:25+00:00

TELEHEALTH Intake Form 2020

First Name

Last Name

Phone Number*

Gender
Male Female N/A

DOB

Ideal date for your TELEHEALTH visit (please list 2/3 dates and times)*

Are you a current or existing patient of DASHA®? Yes No

What type of TELEHEALTH services are you interested in?

Back Pain, Neck Pain, Wrist Pain Consultation Stretching and Exercise Therapy Headache Tension Health Coaching

General Health   Nutritional Recommendation Pain Management Strength Training Postural Ergonomics
Stress  Follow-up Treatment Plans  Breath Work
Yoga Instruction  Holistic Health   Virtual Corporate Wellness

Referred By:

What is your TELEHEALTH tool:

iphone ipad computer