EmailMe Form - Ionic Spa appointment

I'm a new client : *

yes

no

(For new clients, there is a $10 file opening fee.)

First name *

Last name *

Email *

Phone number *

### - ### - ####

Address *

Town / Village *

Postal Code *

Date of Birth :

DD / MM / YYYY

DD = day, MM = month, YYYY = year
Exemple : 24/02/1975

My choice is : *

Ionic spa (15 min) with foot massage (30 min) / ($55)

Ionic spa (30 min) with foot massage (3o min) / ($80)

Ionic spa 15 min ($25)

Ionic spa 30 min ($40)

I have allergies and/or intolerances to essential oils, incense, perfume or other. *

yes

no

other

If any, specify in Important note(s).

For my Ionic Spa appointment, I choose the following essential oil blend (in diffusion):

Balancing

Anchorage

Meditative

No Thanks! Not for me!

Important note(s) :
(pain, allergies, etc.)

Checkmark the moment to receive the massage.

morning

afternoon

evening

Checkmark your preferences.

My method of paiment: *

Naturotherapy receipt *

I need one. Thanks!

I don't need one.

Please use the following way to reach me : *

Email

Phone

text message

Facebook

For texting, please provide me a mobile phone number that Iwill be able to use to confirmat your massage appointment.