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For clients wishing to bill insurance, please allow up to 3 days for approval and verification.

Membership Request, Insurance Billed

First name*

Last name*

Email*

Phone*

Birthday*

Month

Day

Year

Address*

City Zip*

Membership Type*

Approved Insurance Program (One Time $10 fob fee)$10

Insurance ID Number*

Insurance Program Name*

Liability Release

Photo of Primary Account Holder *

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