Locations in the U.S. and U.K.

World Phone: 1-352-336-1433

UK Phone: 0808-1453738

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Forms

forms

Thank you for choosing Clear Passage. To expedite treatment scheduling or wrap-up, please fill out the appropriate form(s) from the list below.

Comprehensive Medical History Form

To get the most from your consultation and possible treatment, please complete our Comprehensive Medical History Form (takes about 30 minutes). Because we treat the adhesions that occur whenever we heal in life, be sure to include all lifetime healing events: (e.g. surgeries, infections, traumas, accidents, falls, abuse).

Exit Survey

Tell us about your experience at Clear Passage. We value your comments in our ongoing effort to improve our patient care.

Physician’s Clearance (for infertility patients)
Physician’s Clearance (for all other patients)

Clearance forms are required as part of your application for therapy. Please print and bring this form to your physician for them to sign. The form indicates any contraindications or cautions that we need to be aware of, in order to treat you safely.

Provider Questionnaire

Are you interested in working with us? Complete our provider questionnaire to see if your skills and experience fit our clinical needs.

Re-Evaluation Form

Would you like to return to Clear Passage to receive more therapy? Complete our re-evaluation form.

Patients with Pain

Insurance suggestions and documents for patients with pain

Patients with Bowel Obstructions

Insurance suggestions and documents for patients with a history of bowel obstruction

Insurance coverage request

Complete this form, sign it at the bottom, and send it to your insurer as an inquiry, claim or appeal.

Please contact us with any questions about completing or submitting these forms.