Customer Data Form

Information on this form is necessary for reimbursement from insurance. Touching You, Inc., follows all guidelines of “The Privacy Act”.

Please fill out this form prior to your appointment as it will greatly speed up your visit with us. We will also need copies of your insurance card(s) and driver's license.

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Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.
Your Name(Required)
Your Address(Required)
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*if different from customer (If filing with carrier other than customer's)
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Have you had a Mastectomy/Lumpectomy?(Required)
MM slash DD slash YYYY
Check if You've Had Any of the Following
Customer’s or authorized person’s signature(Required)
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Customer’s or authorized person’s signature
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How Did You Hear About Touching You?

Would you like to be contacted by email for notifications of new products, special events and sales from Touching You and, our online store, Your Encore Life?(Required)