Non-Swedish Medical Center Massage Requests

Name *

Name

First Name

Last Name

Email Address *

Phone (prefer mobile)

(###)

###

####

Medical Center Name *

Medical Center Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Health Need *

Briefly describe the state of your health and how it pertains to your massage needs.

Menu Item

Refer to our menu for the type of massage you desire.

Your Room

If your room does not have a hydraulic bed for the therapist to work in, the room will need to be large enough to accommodate working around her massage table for services 60+ minutes. A massage or reclining chair may be used for services 30 minutes or less.

Hydraulic Bed?

Room for Massage Table?