Please print this Insurance Form and have it completed
by a licensed health care practitioner.

Name:

_______________________

___________________

____________

Last

First

Middle

Home Address:

__________________________________________

Home Phone:

( ____ ) ______ - __________

Date of Birth:

______/______/______

Sex: M F

Next of Kin:

_______________________

Phone: __________________

Health Insurance Information

Company:

___________________________________________

Address:

___________________________________________

Policy or Contract #

__________________________

Exp Date:

____________

HEALTH INSURANCE IS REQUIRED FOR ACCEPTANCE INTO PROGRAM. INCLUDE A PHOTOCOPY OF YOUR INSURANCE WITH THIS FORM

Have you had surgery? Yes _____ No _____
If yes, please list:

Do you take medication, pills, or use other drugs regularly? Yes _____ No ______
If yes, please list:

Please list all health care providers:

Name	Phone:
____________________________________	____________________
____________________________________	____________________
____________________________________	____________________

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Wicks Educational Associates, Inc., Maple Building, Suite 202, 5012 Lenker Street, Mechanicsburg, PA 17055; Phone: 1.800.807.WICKS or 717.737.2770; Fax: 717.737.7683; E-Mail: wicks@epix.net

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Please print this Insurance Form and have it completed by a licensed health care practitioner.

Please print this Insurance Form and have it completed
by a licensed health care practitioner.