Body Solutions Inc

Contact Information

First Name

Last Name

Date Of Birth (Mm/Dd/Yyyy) *

Street Address 1*

City*

State*

Postal Code*

Primary Email *

Home Phone *

Cell Phone *

Cell Phone Carrier
Please select oneAt&tTMobileSprintVerizone

Emergency Contact and Medical Contact

Emergency Contact Name *

Emergency Phone Number *

Primary Care Physician Name

Physican Phone (If Unknown, Name City He Or She Is In)

General And Medical Information Do You Suffer From Any Of The Below?

Heart Condition*
YesNo
High Blood Pressure*
YesNo
Blood Clots*
YesNo

Varicose Veins*
YesNo
Cancer*
YesNo
Diabetes*
YesNo

Urinary Problems*
YesNo

Muscle/Joint Pain*
YesNo
Nerve Pain, Tingling, Loss Of Sensation*
YesNo

Arthritis*
YesNo
Respiratory Problem*
YesNo
Skin Problems*
YesNo

Headaches / Migraines*
YesNo

Herniated Or Bulding Discs In The Neck Or Back*
YesNo

Allergies*
YesNo
Fibromyalgia*
YesNo

General Information To Maximize Safety And Effectiveness Of Your Massage Treatment

Have You Ever Had A Massage? If So What Type?*

Are You Currently Pregnant? If So How Far Along?*

Have You Previously Had Any Surgeries? If So List Where*

Are You Currently Under The Care Of A Doctor? If So, List Name*

Are You Allergic Or Sensitive To Any Oils (Nuts, Scents,Etc)?*

Which Of The Area(S) Would You Like The Therapist To Focus On? *

What Are Your Goals For Your Massage Therapy Treatment Program?*

Do You Have Time To Perfrom Recommended Therapeutic Exercises?*
YesNo

Please follow our 24 hour cancellation policy. If you have to change your appointment please call us directly at 856-751-8881 within 24 hours of your appointment time or you will be charged the value of your scheduled massage.

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