Massage Intake Form


Massage Intake Form

Massage Therapy Intake Form

Welcome! We want to make your stay as pleasant and as comfortable as possible. If you have any questions regarding your therapy session, please let us know.

  • MM slash DD slash YYYY
  • Insurance Provider:Member ID:Group ID:Policyholder's Name (if different from yours):Date of Birth of Policyholder:Phone Number for Insurance Provider (if available): 
    Please fill out the required fields to the best of your knowledge. This information will help us verify your insurance coverage for medical massage. We will contact you via phone and or email within 7 business days.
    Please note: It's essential to review the specific details of your medical insurance policy to determine if massage therapy is covered and under what circumstances. You can do this by checking your insurance policy documents or by contacting your insurance provider directly to inquire about coverage for massage therapy.
  • Treatment Consultation:

    (Additional fees may apply. Based on availability)
  • Pre-Natal Massage Section

    Welcome and Congratulations! We want to take the very best care of you and your baby, so relax and enjoy your treatment with our fully capable NYS Licensed Therapist.
  • This field is for validation purposes and should be left unchanged.
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