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Prescription Form

  • Private pay or Insurance? Call us for a free consultation: 813-631-9700
  • Click here to Download Patient Prescription Form. Print out and bring to your physician, ask him/her to sign for your Therapy asap.
  • Fill out the physician's info below and we'll request for you.
Your Name: First   Last (*)
Email: (*)
Date of Birth:
Insurance info:
Private Pay?  Yes     No
Name of Insurance company:
Policy number:
Group number:
Provider phone number:
HMO plan?  Yes    No
Have a Secondary insurance info?  Yes    No
Secondary Name of Insurance company:
Secondary Policy number:
Secondary Group number:
Secondary Provider phone number:
Physician Name: First   Last
Practice Name:
Address 1:
Address 2:
Address 3:
What problems are you seeking treatment for?
Any particular staff there whom we should ask for?
Any special message from you to the physician's office?
Any special message to us?


Decide, take charge of your better health today!

Thank you for visiting Ginger, Have a Harmonious and Healthy Year!