Do you have health insurance? Depending on your company and policy, there is a possibility that massage and/or acupuncture are covered benefits. We encourage you to contact a customer service representative with your insurance company. We also provide complimentary insurance verification.

Each person’s insurance coverage on your plan (or any other plan) needs to be verified SEPARATELY. Examples include: spouse, children, parent, etc.

Insurance appointments can be booked ONLY after you have received a confirmation of coverage from us. If you do book online, please be sure to choose from the “Billed Services” category of appointments. Failure to receive verification will result in your appointment being considered out-of-pocket.

Due to the currently high volume of insurance verifications, please allow several weeks for verification to be completed.

Client Name (First, Last)

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please check your preferred method of contact for coverage details

Please allow at least 2 BUSINESS DAYS for verifications to be completed. If you would like to contact our insurance department directly you may do so via email at insurance@thepearldayspa.com or by calling 541-683-3377 ext. 102 Appointments may only be booked after your information has been verified and confirmed.

E-Mail

Phone

Referred by:

Please let us know how your heard about us (friend, family member, co-worker, medical provider, Google, Facebook, etc.). It was another client, please name them here.

Client Birth Date

MM

DD

YYYY

Primary insured Member Name

Relationship to Insured (Spouse, Parent, Self, Etc

Primary or Secondary Coverage

If you have secondary insurance coverage, please submit this form once with your primary, and again with your secondary.

Insurance Company Name

ID Number

Group Number

Subscriber Employer