Please complete the following form to request information about insurance coverage.

Name: Green Spa & Wellness Center
Address: 8804 Third Avenue Bay Ridge ,, Brooklyn, Ny, 11209, USA
Telephone: (718) 921-6100

Company
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Name*
First Last
Email*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Insurance Type*
Insurance Number*
Date of Birth*
Provider's phone number on the back of the card:
Please list which services you may be interested in for insurance coverage:
- Acupuncture treatments
- Alternative care
Please list any specific condition you wish to target at The Green Spa & Wellness Center:
Notes & Requests: