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First & Last Name
Date of Birth
Address (*Please fill complete address, city, state, zip)
Name of Insurance (indicate "none" if not using)
If none, specify none.
What is the reason you are seeking help? List the issues you are concerned about or anything preventing you from living your best life.
List in order of priority and rank each one you chose on a scale (1-10) 10 being the worst
What medications are you taking?
I will pay by credit card, check or cash.
Paid via ClassPass, Groupon or other Offer.
I plan to use my insurance to cover.
I am not sure about payment yet but my health is #1 to me and I will figure out a way to make it work.
I don't know how I can pay for this, what are my options.
I want to be sponsored
PLEASE ADD ANYTHING ELSE YOU WOULD LIKE TO COMMENT ON HERE:
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Name of individual you are signing on behalf of:
We accept insurance for PPOs with "out of network coverage". We do not accept Kaiser, HMOs, Medicaid or Medicare. If you have Blue Sheild, you need to pay in advance as the check will be mailed to you. Payment for services are expected and reimbursment will come depending upon your benefits, deductible and eligibility.
In order to submit to your insurance, please fill out your date of birth & address. Email the front and back of your insurance card to email@example.com. Ask your doctor to write a prescription to have neuro-feedback and infrared light therapy as needed due to your condition.
INSURANCE POLICY / DEDUCTIBLE:
IF PAYING VIA INSURANCE A COPAY WILL BE REQUIRE PRIOR TO ANY AND ALL SERVICES.
Metatron Quantum Scanner is awesome for prevention. See what virus, bacteria, heavy metals, parasites and more!
I want a high level scan for $49.
I want the deepest scan for $499.
Info Needed for Scan
Sensitivities (light, noise, food)
Have you had any of the following: Seizures, Tourettes, Migraines, Ticks
Place of Birth (city, state, country)
Time of Birth
The form will not submit unless all fields are filled out, missing information will highlight in red for you to correct them.
Please hand back to your provider to submit. Thank you!
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LOCATIONS We Serve:
New York, NY
Las Vegas, NV
Sun Valley, ID
Brain Wellness Therapy
by Inlight Medical(TM)
Metatron NLS Scaner
Inlight Medical Service
Infrared Light Therapy
Brain Spa By FisherWallace(TM)
Brain Spa by NeuroOptimal(TM)
Natural Healing With Pets
Brain Training by Brain-Trainer(
Mental Health Center
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All Rights Reserved ~ 2012-2019
These statements have not been evaluated by the FDA. Not intended to diagnose, treat, or cure any disease.