Contact – Renew TMS

Get Connected To Us Easily

Our Address

4000 Long Beach Blvd., Suite 228, Long Beach, CA 90807

Our Phone

Office Telephone : (562) 637-3142

Our Email

Main Email : info@renewtms.org
Inquiries : tms_Renewclinic@aol.com

Our Email

Main Email : info@renewtms.org
Inquiries : tms_Renewclinic@aol.com

NEW CLIENT INFORMATION

Online form to enter new client and insurance information that will help setup a new administrative account in our system.
Please fill out and submit the following forms as they apply to your situation.

Today’s Date: >

Firstname:

Lastname:

Date of Birth:

Gender:

Address 1:

Address 2:

City:

State:

Zip Code:

Email Address:

Primary Phone:

Secondary Phone:

Insurance Information

Will you be using Health Insurance?

Insurance Name:

Insurance ID:

Subscriber Information

Are you the main subscriber on this policy?

Main Subscriber Firstname:

Main Subscriber Lastname:

Main Subscriber:

Phone No:

Employer:

Occupation:

Patient Relation to Subsriber: