Lourdes Wellness Center

Phone: (856) 869-3125    Fax:(856) 869-3129

If you would like to schedule a massage or bodywork session online, please complete the information below.  Please book your appointment at least two business days in advance.  Thank you.

1. Service Requested (Prices below do not include tax):
 
2. Requested Day:
 
3. Requested Date:
MM/DD/YY

4. Requested Time (Please wait to hear from us to confirm your requested appointment time):
 
5. Phone (Including Area Code):
         
6. Email:

7. Full Name:

8. Address:
  
9. City:
  
10. State:
11. Zip Code:
12. Age:

13. Recommended by:

14. Reason for visit:
 

15. Check any of the following that are applicable to you:
  Arthritis
  Bone Fractures
  Cancer
  Contact Lenses
  Diabetes
  Heart Condition
  Hypertension
  Infection/Inflammation (s)
  Muscle Disease
  Pregnancy
  Thrombosis
  Varicose Veins
 15(a). Other:
16. Medications
 
17. Allergies

18. Operations

19. Last Physical Exam:
 
20. Present complaint:
 
 20(a). If yes, when did it start?
20(b). Injury?
21. Have you had a massage before? Yes No
22. Do you exercise regularly? Yes No
22(a). If yes, what type?
23. Are you satisfied with your nutrition? Yes No
24. Do you take vitamins and/or minerals? Yes No
25. Do you smoke? Yes No
25(a). If yes, amount:
26. Do you drink coffee? Yes No
27. Do you drink tea? Yes No
28. Do you drink alcohol? Yes No
29. Would you like to be added to our email list? Yes No

Thank you for scheduling your appointment with       Lourdes Wellness Center.  Have a great day!