Paperwork | Massage Loft Florida

<form action='https://www.secure-booker.com/MassageLoftsFlorida/WebToCustomer.aspx' method='POST' id='form49238d25' onsubmit='javascript:submit49238d25();'>
<input type='hidden' id='OnSuccessUrl' name='OnSuccessUrl' value='https://www.massagelofts.net/book-appointments'/>
<input type='hidden' id='SpaID' name='SpaID' value='k6VRusZraKU4+raidsYjdwrKrrHeGeWvYNgRDK9CB4bi'/>
<input type='hidden' id='RequiredFields' name='RequiredFields' value='FirstName,LastName,Email,AddressStreet1,AddressCity,AddressState,AddressPostalCode,Birthday,CustomField_52441,CustomField_52452,CustomField_52449,CustomField_52448,CustomField_52451,CustomField_52450,Occupation'/>
<table>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='FirstName49238d25Label' for='FirstName'>First Name</label></td><td><input type='text' id='FirstName' name='FirstName' required maxlength='50'/></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='Email49238d25Label' for='Email'>Email</label></td><td><input type='text' id='Email' name='Email' required maxlength='255'/></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='AddressStreet149238d25Label' for='AddressStreet1'>Address Street 1</label></td><td><input type='text' id='AddressStreet1' name='AddressStreet1' required maxlength='100'/></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='AddressCity49238d25Label' for='AddressCity'>Address City</label></td><td><input type='text' id='AddressCity' name='AddressCity' required maxlength='50'/></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='AddressState49238d25Label' for='AddressState'>Address State</label></td><td><select id='AddressState49238d25' name='AddressState' >
<option value=''>Any State</option>
<option value='AK'>AK</option>
<option value='AL'>AL</option>
<option value='AR'>AR</option>
<option value='AS'>AS</option>
<option value='AZ'>AZ</option>
<option value='CA'>CA</option>
<option value='CO'>CO</option>
<option value='CT'>CT</option>
<option value='DC'>DC</option>
<option value='DE'>DE</option>
<option value='FL'>FL</option>
<option value='FM'>FM</option>
<option value='GA'>GA</option>
<option value='GU'>GU</option>
<option value='HI'>HI</option>
<option value='IA'>IA</option>
<option value='ID'>ID</option>
<option value='IL'>IL</option>
<option value='IN'>IN</option>
<option value='KS'>KS</option>
<option value='KY'>KY</option>
<option value='LA'>LA</option>
<option value='MA'>MA</option>
<option value='MD'>MD</option>
<option value='ME'>ME</option>
<option value='MH'>MH</option>
<option value='MI'>MI</option>
<option value='MN'>MN</option>
<option value='MO'>MO</option>
<option value='MP'>MP</option>
<option value='MS'>MS</option>
<option value='MT'>MT</option>
<option value='NC'>NC</option>
<option value='ND'>ND</option>
<option value='NE'>NE</option>
<option value='NH'>NH</option>
<option value='NJ'>NJ</option>
<option value='NM'>NM</option>
<option value='NV'>NV</option>
<option value='NY'>NY</option>
<option value='OH'>OH</option>
<option value='OK'>OK</option>
<option value='OR'>OR</option>
<option value='PA'>PA</option>
<option value='PR'>PR</option>
<option value='RI'>RI</option>
<option value='SC'>SC</option>
<option value='SD'>SD</option>
<option value='TN'>TN</option>
<option value='TX'>TX</option>
<option value='UT'>UT</option>
<option value='VA'>VA</option>
<option value='VI'>VI</option>
<option value='VT'>VT</option>
<option value='WA'>WA</option>
<option value='WI'>WI</option>
<option value='WV'>WV</option>
<option value='WY'>WY</option>
</select>
</td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='AddressPostalCode49238d25Label' for='AddressPostalCode'>Address Postal Code</label></td><td><input type='text' id='AddressPostalCode' name='AddressPostalCode' required maxlength='20'/></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='Birthday49238d25Label' for='Birthday'>Birthday</label></td><td><select id='BirthdayMonth' name='BirthdayMonth'>
<option value=''>Month</option>
<option value='1' >1</option>
<option value='2' >2</option>
<option value='3' >3</option>
<option value='4' >4</option>
<option value='5' >5</option>
<option value='6' >6</option>
<option value='7' >7</option>
<option value='8' >8</option>
<option value='9' >9</option>
<option value='10' >10</option>
<option value='11' >11</option>
<option value='12' >12</option>
</select>
<select id='BirthdayDay' name='BirthdayDay'>
<option value=''>Day</option>
<option value='1' >1</option>
<option value='2' >2</option>
<option value='3' >3</option>
<option value='4' >4</option>
<option value='5' >5</option>
<option value='6' >6</option>
<option value='7' >7</option>
<option value='8' >8</option>
<option value='9' >9</option>
<option value='10' >10</option>
<option value='11' >11</option>
<option value='12' >12</option>
<option value='13' >13</option>
<option value='14' >14</option>
<option value='15' >15</option>
<option value='16' >16</option>
<option value='17' >17</option>
<option value='18' >18</option>
<option value='19' >19</option>
<option value='20' >20</option>
<option value='21' >21</option>
<option value='22' >22</option>
<option value='23' >23</option>
<option value='24' >24</option>
<option value='25' >25</option>
<option value='26' >26</option>
<option value='27' >27</option>
<option value='28' >28</option>
<option value='29' >29</option>
<option value='30' >30</option>
<option value='31' >31</option>
</select>
<select id='BirthdayYear' name='BirthdayYear'>
<option value=''>Year</option>
<option value='2024' >2024</option>
<option value='2023' >2023</option>
<option value='2022' >2022</option>
<option value='2021' >2021</option>
<option value='2020' >2020</option>
<option value='2019' >2019</option>
<option value='2018' >2018</option>
<option value='2017' >2017</option>
<option value='2016' >2016</option>
<option value='2015' >2015</option>
<option value='2014' >2014</option>
<option value='2013' >2013</option>
<option value='2012' >2012</option>
<option value='2011' >2011</option>
<option value='2010' >2010</option>
<option value='2009' >2009</option>
<option value='2008' >2008</option>
<option value='2007' >2007</option>
<option value='2006' >2006</option>
<option value='2005' >2005</option>
<option value='2004' >2004</option>
<option value='2003' >2003</option>
<option value='2002' >2002</option>
<option value='2001' >2001</option>
<option value='2000' >2000</option>
<option value='1999' >1999</option>
<option value='1998' >1998</option>
<option value='1997' >1997</option>
<option value='1996' >1996</option>
<option value='1995' >1995</option>
<option value='1994' >1994</option>
<option value='1993' >1993</option>
<option value='1992' >1992</option>
<option value='1991' >1991</option>
<option value='1990' >1990</option>
<option value='1989' >1989</option>
<option value='1988' >1988</option>
<option value='1987' >1987</option>
<option value='1986' >1986</option>
<option value='1985' >1985</option>
<option value='1984' >1984</option>
<option value='1983' >1983</option>
<option value='1982' >1982</option>
<option value='1981' >1981</option>
<option value='1980' >1980</option>
<option value='1979' >1979</option>
<option value='1978' >1978</option>
<option value='1977' >1977</option>
<option value='1976' >1976</option>
<option value='1975' >1975</option>
<option value='1974' >1974</option>
<option value='1973' >1973</option>
<option value='1972' >1972</option>
<option value='1971' >1971</option>
<option value='1970' >1970</option>
<option value='1969' >1969</option>
<option value='1968' >1968</option>
<option value='1967' >1967</option>
<option value='1966' >1966</option>
<option value='1965' >1965</option>
<option value='1964' >1964</option>
<option value='1963' >1963</option>
<option value='1962' >1962</option>
<option value='1961' >1961</option>
<option value='1960' >1960</option>
<option value='1959' >1959</option>
<option value='1958' >1958</option>
<option value='1957' >1957</option>
<option value='1956' >1956</option>
<option value='1955' >1955</option>
<option value='1954' >1954</option>
<option value='1953' >1953</option>
<option value='1952' >1952</option>
<option value='1951' >1951</option>
<option value='1950' >1950</option>
<option value='1949' >1949</option>
<option value='1948' >1948</option>
<option value='1947' >1947</option>
<option value='1946' >1946</option>
<option value='1945' >1945</option>
<option value='1944' >1944</option>
<option value='1943' >1943</option>
<option value='1942' >1942</option>
<option value='1941' >1941</option>
<option value='1940' >1940</option>
<option value='1939' >1939</option>
<option value='1938' >1938</option>
<option value='1937' >1937</option>
<option value='1936' >1936</option>
<option value='1935' >1935</option>
<option value='1934' >1934</option>
<option value='1933' >1933</option>
<option value='1932' >1932</option>
<option value='1931' >1931</option>
<option value='1930' >1930</option>
<option value='1929' >1929</option>
<option value='1928' >1928</option>
<option value='1927' >1927</option>
<option value='1926' >1926</option>
<option value='1925' >1925</option>
<option value='1924' >1924</option>
<option value='1923' >1923</option>
<option value='1922' >1922</option>
<option value='1921' >1921</option>
<option value='1920' >1920</option>
<option value='1919' >1919</option>
<option value='1918' >1918</option>
<option value='1917' >1917</option>
<option value='1916' >1916</option>
<option value='1915' >1915</option>
<option value='1914' >1914</option>
</select>
</td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='CustomField_5244149238d25Label' for='CustomField_52441'>Current Medications</label></td><td><select id='CustomField_52441' name='CustomField_52441' multiple required>
<option value='578746'>Anxiety or Depression Medications</option>
<option value='578747'>Blood Pressure Medications</option>
<option value='578748'>Blood Thinners</option>
<option value='578749'>Corticosteroids (prednisone, cortisone)</option>
<option value='578750'>Diabetic Medications (metformin, insulin)</option>
<option value='578751'>Diuretics (water pills)</option>
<option value='578752'>Dopaminergics (medication for Parkinson's)</option>
<option value='578753'>Heart Medications</option>
<option value='578754'>Muscle Relaxants</option>
<option value='578755'>Narcotic Pain Relievers</option>
<option value='578756'>NSAIDS (Ibuprofen, naproxen, celebrex, aspirin)</option>
</select></td></tr>

<tr><td><span style='color: transparent; margin: 0 3px;'>*</span><label id='CustomField_5244249238d25Label' for='CustomField_52442'>Are you pregnant?</label></td><td><input type='checkbox' id='CustomField_52442' name='CustomField_52442' /><input type='hidden' value='false' name='CustomField_52442' /></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='CustomField_5245249238d25Label' for='CustomField_52452'>Do you have a condition that is not listed?</label></td><td><textarea id='CustomField_52452' name='CustomField_52452'>required</textarea></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='CustomField_5244949238d25Label' for='CustomField_52449'>Do you have any orthopedic injuries?</label></td><td><textarea id='CustomField_52449' name='CustomField_52449'>required</textarea></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='CustomField_5244849238d25Label' for='CustomField_52448'>Have you been diagnosed with any of the following conditions?</label></td><td><select id='CustomField_52448' name='CustomField_52448' multiple required>
<option value='578775'>Arthritis</option>
<option value='578776'>Blood Clots</option>
<option value='578777'>Broken Bones</option>
<option value='578778'>Cancer</option>
<option value='578779'>Diabetes</option>
<option value='578780'>Fibromyalgia</option>
<option value='578781'>Headaches/Migraines</option>
<option value='578782'>Heart Attack</option>
<option value='578783'>High/Low Blood Pressure</option>
<option value='578784'>Joint Replacement</option>
<option value='578785'>Kidney Dysfunction</option>
<option value='578786'>Neuropathy</option>
<option value='578787'>Numbness</option>
<option value='578788'>Sprains or Strains</option>
<option value='578789'>Stroke</option>
</select></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='CustomField_5245149238d25Label' for='CustomField_52451'>Have you had surgery in the last 2 years?</label></td><td><textarea id='CustomField_52451' name='CustomField_52451'>required</textarea></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='CustomField_5245049238d25Label' for='CustomField_52450'>Pressure Preference</label></td><td><select id='CustomField_52450' name='CustomField_52450' required>
<option value='578791'>Light</option>
<option value='578792'>Medium</option>
<option value='578793'>Deep</option>
</select></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='Occupation49238d25Label' for='Occupation'>Occupation</label></td><td><input type='text' id='Occupation' name='Occupation' required maxlength='100'/></td></tr>

</table>
<br/>
<input type='submit' value='Save'/>
<script type='text/javascript'>

var usaId49238d25 = 1;
var canadaId49238d25 = 2;
var phonesIds49238d25 = '';
function ChangePhonesAndStates49238d25(updateFull){
var obj = document.getElementById('AddressCountry49238d25');
var isNANPA = false;
var currVal;
if (obj && obj.value != ""){
currVal = obj.value;
} else {
currVal = 1;
}
isNANPA = usaId49238d25 == currVal || canadaId49238d25 == currVal;
var phones = phonesIds49238d25.split(';');
for(var i=0;i<phones.length;i++){
if (!document.getElementById(phones[i] + 'FullPhone')){
break;
}
if (isNANPA){
document.getElementById(phones[i] + 'Phone1').parentNode.style.display = 'inline';
document.getElementById(phones[i] + 'FullPhone').parentNode.style.display = 'none';
} else {
document.getElementById(phones[i] + 'FullPhone').parentNode.style.display = 'inline';
document.getElementById(phones[i] + 'Phone1').parentNode.style.display = 'none';
}
if (updateFull && isNANPA){
document.getElementById(phones[i] + 'FullPhone').value = document.getElementById(phones[i] + 'Phone1').value + document.getElementById(phones[i] + 'Phone2').value + document.getElementById(phones[i] + 'Phone3').value;
}

}

// update states list
var statesObj = document.getElementById('AddressState49238d25');
if (statesObj != null) {
var statesLabelObj = document.getElementById('AddressState49238d25Label');
var isUS = obj.value != '' && usaId49238d25 == currVal;
statesObj.style.display = isUS ? '' : 'none';
statesLabelObj.style.display = isUS ? '' : 'none';
if (isUS){
// we select the first item - Any state
statesObj.options[0].selected = true;
}
}

}

ChangePhonesAndStates49238d25(false);

function submit49238d25(){
ChangePhonesAndStates49238d25(true);
}

</script>
</form>

Massage Lofts Florida