EmailMe Form - PACKAGE APPOINTMENT FORM

I'm a new client : *

yes

no

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

First name *

Last name *

Email *

Phone numbefr *

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

Address *

Town / Village *

Postal Code *

Date of Birth :

DD / MM / YYYY

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

For my treatment, I choose this package (165$) : *

EXTRA (optional)
(This amount will be added to the chosen massage.) *

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

No thanks!

Hot stones are used to help you relax.

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

oui

non

autre(s)

If any, specify in Important note(s).

For my package, 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: *

Massage therapy and Naturotherapy receipt *

yes

no

Depending on the package, the amount paid will be shared in Massage Therapy and Naturotherapy.

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.