HHMMF Massage Request
It is our sincere desire that no one goes to bed in pain, and all who receive these services are able to relax in order to help the body heal.

To learn more about our foundation, visit us on the web: hhmmf.org/, like us on Facebook, or follow us on Twitter: @HHMM_Foundation.

If you, or someone you know, are in need of a therapeutic massage, and do not have insurance that will cover massages, please complete the following information. Upon completion, please submit it for review.

Sincerely,
Joey Gall
President, Healing Hands of Mercy Massage Foundation, Inc

Today's Date *
MM
/
DD
/
YYYY
Full Name *
Your answer
Contact Number *
Your answer
Email address
Your answer
Gender *
Age *
How did you hear about the HHMM Foundation? *
Your answer
Condition/situation warranting massage (i.e., recent hospitalization, currently in hospital/hospice care, home-bound patient, caregiver for seriously ill or terminal patient, recent surgery, prolonged illness, etc.) *
Your answer
Are you in agreement that your therapist and a representative of HHMMF will be able to speak about your medical/massage needs in a confidential manner as needed? *
Required
Are you able to travel and receive your massage at a massage facility? *
Location and address to receive massage (i.e., home, hospital, nursing home, rehab facility, massage studio, hospice, etc.): *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service