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

U.S. & CANADA: 1-866-222-9437

UNITED KINGDOM: 0808-1453738

OTHER: 001-352-3361433

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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.

Insurance Coverage Request ─ for Bowel Obstruction patients

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

Physicians Referral (pdf)

Do you need a physician’s referral for insurance reimbursement? Print this form for your physician to complete prior to receiving treatment. This form is required for those receiving treatment at our California clinic.

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.

Request a Free Consultation

Want to speak with a therapist to receive more information about a specific condition? Complete our online form.

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