Want to Get Your Hands On Our BEST Massage Therapy Secrets?

Then Just Fill Out the Form Below and Gain Instant Access to Our $29.95 eBook for free!
  • Get rid of your own neck and back pain!
  • Absolutely No Purchase Required–It’s Totally Free!
  • Learn the Techniques and Surprise Your Loved One!
Complete the Form below for Immediate Access:

Massage Intake

    • FirstName*
    • LastName*
    • Birthday*
    • Street Address 1*
    • City *
    • State *
    • Postal Code*
    • Primary Email *
    • Home Phone *
    • Cell Phone *
    • Cell Phone Carrier
    • Emergency Contact *
    • Emergency Contact Phone *
    • 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*
      YES
      NO
    • High Blood Pressure*
      YES
      NO
    • Blood Clots*
      YES
      NO
    • Varicose Veins*
      YES
      NO
    • Cancer*
      YES
      NO
    • Diabetes*
      YES
      NO
    • Urinary Problems*
      YES
      NO
    • Muscle/Joint Pain*
      YES
      NO
    • Nerve Pain, Tingling, Loss of Sensation*
      YES
      NO
    • Arthritis*
      YES
      NO
    • Respiratory Problem*
      YES
      NO
    • Skin Problems*
      YES
      NO
    • Headaches / Migraines*
      YES
      NO
    • Herniated or Bulding Discs In The Neck Or Back*
      YES
      NO
    • Allergies*
      YES
      NO
    • Fibromyalgia*
      YES
      NO
    • 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?*
      YES
      NO

Client’s Testimonials


  • Penny Bilofsky
    “Love working with Jason feels like he really listens to me. I am working on weight loss which is slow and he keeps me motivated”

  • Steve Paglione
    “I have been working out at Body Solutions for 7 weeks now. I have never been happier with a facility or trainer. Rich Pohler takes the time to get to know his clients’ limitations and designs a workout specifically for them. I have achieved great results in just 7 weeks with Rich. My chest, arms, and legs have grown, while my waist has shrunk. I am confident that Rich can help anyone reach their goals.”

  • Colleen Normandin
    “I discovered Body Solutions through a Groupon. I bought two massages, one for my daughter and one for myself. We were both so impressed with the we are continuing to return for follow-up sessions.”

  • Connie Wagner
    “This was my first experience with a massage that was much more, a medical message.Victor first pinpointed my weak points and told me that I am probably having issues in specific areas. I get pleasure telling friends about Victor because I know they will get results. ”

Want to Get Your Hands On Our BEST Massage Therapy Secrets?

Then Just Fill Out the Form Below and Gain Instant Access to Our $29.95 eBook for free!

  • Get rid of your own neck and back pain!
  • Absolutely No Purchase Required–It’s Totally Free!
  • Learn the Techniques and Surprise Your Loved One!

Complete the Form below for Immediate Access:

  • First Name:
  • Email:
*We will never sell or rent your information. You will only get awesome tips and secrets from us only.