Massage Order Form

Massage Order Form
All of our massage experts are pre-screened and quality approved; professional ethics and integrity are the roots of our success.
Use the form below to schedule your next appointment. To talk to one of our operators please call toll free:
USA 1-800-946-2772 or International 1-561-379-3224.
For your convenience we accept all major Credit Cards.

Please provide the following contact information:

Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail

Please describe yourself:

Age Height Weight

Gender Male Female

Reason for Massage:
Select any of the following reasons that apply:

Stress
Neck Pain
Back Pain
Headache
Other...Explain: Improve Circulation
Total Maintenance
Medical
Achy Feet

Choose gender preference:

Female Therapist Male Therapist

Choose from one of the following sessions:

Note: The price includes $10 OFF Internet order discount

For even greater savings Select our discounted Memberships:

Please enter appointment date & time:

-- mm/dd/yy
-- hh:mm:ss am/pm

	BILLING INFO:
Credit card
Cardholder name
Card number
Expiration date

Additional comments... ?

USA
1(800)946-2772

International:
1(561)795-7557