FREE TRIGGER POINT MASSAGE
TO QUALIFY, PLEASE FILL OUT THE FORM BELOW.     YOU WILL BE CONTACTED TO SCHEDULE YOUR APPOINTMENT.     YOU MAY ALSO CONTACT US DIRECTLY AT 845-342-0000 TO SCHEDULE YOUR FREE MASSAGE.     WE LOOK FORWARD TO HEARING FROM YOU.

FIRST NAME                     LAST NAME
     
STREET ADDRESS

CITY                           STATE        ZIP CODE
          

DAYTIME PHONE                 EVENING PHONE
   
EMAIL

AGE           OCCUPATION
    

DESCRIBE THE TYPES OF PAIN OR TENSION YOU GET
WHEN YOU ARE MOST UNDER STRESS.

ARE YOU RECEIVING ANY TYPE OF CARE FOR THIS CONDITION
RIGHT NOW OR HAVE YOU RECEIVED CARE, EVALUATION
OR TREATMENT IN THE PAST?
                                               YES     NO

IF SO PLEASE DESCRIBE WHAT TYPE OF DOCTOR OR
SPECIALIST AND THE TYPE OF CARE RECEIVED.

WHAT IS THE BEST DAY AND TIME FOR YOUR MASSAGE?

DAY/DATE                       TIME