Form Form

New Client Application Form

Please fill out this form completely.

Lincoln or Yuba City Office

Client's Name




If client is a minor please state their age.


Insured persons name, if different than client


Insured person's ID number


Insurance Company

name of company, authorization number, claims address, Insured ID number if not listed above.

Insurance Authorization Number




Claims Address for Insurance Billing, (not the one on your card)


Your best contact email address


Your best contact Phone Number


Issues to be addressed


Best time of day for appointment-

Lincon Office hours on Tuesday and Thursday.
Yuba City Office hours Wednesdaiy

Merchant Services
Note: All prices in US Dollars
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