Massage Appointment Request

Name *

First

Last

Email *

Phone *

Service Requesting *

Office Location: 539 Keisler Dr. Ste.203, Cary NC 27518

Office Massage Duration *

45 Minute Custom Massage
60 Minute Custom Massage
75 Minute Custom Massage
90 Minute Custom Massage

Select session time desired.

Mobile Massage Durations *

60 Minute Custom Massage
75 Minute Custom Massage
90 Minute Custom Massage
120 Minute Custom Massage

Select session time desired.

Massage Service Enhancements

Essential Oils
Aromatherapy Massage Oil
Sugar Foot Scrub
Bath Salt

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Location the service will be provded.

Date / Time (1st Option) *

//Date

Time

Date / Time (2nd Option)

//Date

Time

Date / Time (3rd Option)

//Date

Time

The best way to notify me: *

Phone Call
Text Message
Email

Check the best way(s) to notify you of appointment status. You may select more than one.

If your appointment is accepted, would you be willing to pay a $20.95 deposit? *

Yes
No

The $20.95 will be deducted from your service charge and/or used in the event of cancellation within our 24 hour cancellation policy or no show policy. If you do not cancel or reschedule appointment before the 24 hour period you will have to pay another $20.95 to reschedule and forfeit the $20.95 deposit already paid.

Credit Card *

Card Number

Security Code

Name on Card

Expiration/

Card on file to be billed for $20 deposit upon appointment acceptance and final confirmation.

Message *

Submit any need to know medical information or request dates and time here.

Signature of Approval *

Picture Upload (optional)

Click or drag a file to this area to upload.

Upload a current picture (head shot only).

Captcha *

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WOULD YOU LIKE TO SUBSCRIBE TO OUR NEWSLETTER? *

YES
NO

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

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