Patient Data Form

    Patient Information:
    All fields marked with * are required.
    *Please have this form completed by your patient to insure correct home address and method of contact

    *First Name
    Middle Initial
    *Last Name
    *Address
    Apt/Unit#
    *City:
    *State:
    *Zip
    *Phone Number:
    *Date of Birth:
    Preferred Method of Contact:

    Luna has gone Green! By providing us with your email, we can help save the Earth. We can email any necessary documents without jeopardizing your Private Health Information, expedite our response time and communicate important information. Our Luna Advocacy Team is also here to discuss any questions, concerns or requests at #1-800-380-4339.

    It’s imperative that we have a good phone number or email address to contact you when we receive measurements from your therapist. Your contact information is used solely for processing your orders. We review your insurance benefits, financial responsibilities and product orders with you before we proceed with order placement. Please keep in mind that some products require authorization prior to order placement.

    *Your email
    *Phone
    Ship Medical Products to:
    *Please select one of the following:
    Physician Information:
    Referring Doctor First Name
    Referring Doctor Last Name
    Referring Doctor Phone
    *Do you have Insurance?
    Primary Insurance Information:
    *Primary Insurance Name:
    *I.D.#:
    *Benefits/Eligibility Phone:
    *Name of Insured (Policy Holder)
    *D.O.B. of Insured (policy holder)
    *Is Medicare the patient’s Primary Insurance?
    *I.D.#:
    *Completed by:

    I accept that this is the legal representation of my signature.
    *Date