EmailMe Form - Healing Therapy appointment

I'm a new client : *

yes

no

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

For my massage, I choose this one : *

EXTRA (optional)
Hot stones are used to help you relax. *

relaxing hot stones(+$20) /this applies for Cayce Reilly massage

No thanks!

This amount will be added to the chosen treatment.

I have already received the following care or consulted: *

Medication *

I take medication.

I don't take medication.

If you are taking medication, please indicate to me in the Important Note(s) section which and why you are taking it. This will help me not to use certain essential oils, so as not to conflict with your medication.

lifestyle habits *

I exercice.

I use relaxation techniques.

none

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

yes

no

other

If any, specify in Important note(s).

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

Checkmark the moment to receive the massage *

morning

afternoon

evening

Checkmark your preferences... *

my method of paiment: *

Massage therapy receipt *

I need one. Thanks!

I don't need one.

According to the A.M.Q., the massage therapist cannot issue a receipt to the holder of the gift certificate because it was issued to the buyer of the latter.

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.