Contact Us

interested in services – have questions?

Send email to info@lifebacknj.com

Call Us:

609-482-3701 (will reach both offices)
Intake Department – Option 2
Billing Department – Option 3

Fax:

609-482-3702

Email:

LET'S Chat

Use the form below to inquire about our services.

LET'S Chat

Use the form below to inquire about our services.

Name

Phone Number

Potential Patient Information

Patient Name:

Date of Birth:

Phone Number:

Email Address:

Additional Information

How did you hear about us?

What are you seeking help for?

Insurance Information

Insurance Company:

Insurance ID Number:

Policyholder Name:

Policyholder Date of Birth:

LifeBack!