New Patient Intake

Please complete this confidential form so our clinical team can prepare for your visit. Your information is encrypted, stored privately, and used solely for the delivery of care.

Submissions are protected with industry-standard encryption in transit and at rest. Only authorized clinic personnel may access your information. Read our HIPAA & Privacy notice.

Patient Information

First Name*

Last Name*

Address*

Best Contact Phone*

Best Email*

Date of Birth*

General Intake Information

Referring Doctor

Type of Work / Occupation

Insurance I (Primary)

Insurance II (Secondary)

Last Massage Place

Type of Therapy Requested

Diagnosis / Concentrate on this area*

Reason for Therapy*

Add Ons and Upgrades (for custom massages only)

Extra 60 mins — $80 · Extra 30 mins — $45 · All other upgrades — $20 each.

Cupping$20Hot stones$20Cold stones$20Red light laser$20Kinesiology taping$20Essential oils$20CBD oils$20Extra 30 mins$45Extra 60 mins$80

I acknowledge that the information I am submitting is accurate to the best of my knowledge, and I authorize Massage Healthcare of America, Inc. to use it to coordinate my care in accordance with their HIPAA & Privacy notice.

Concierge Clinical Care

Physician-prescribed recovery — delivered at your door.

Physician-prescribed lymphatic & musculoskeletal rehabilitation throughout the Las Vegas, Nevada valley — we are 100% mobile and come to the patient. Clinical care for complex surgical, oncology, and chronic pain cases.

Contact

100% Mobile Service We come to the patient Serving the Las Vegas Valley
(775) 515-7770
Fax medical reports(775) 205-2105