I   w o u l d   l i k e   t o   R e q u e s t   a   S e s s i o n

(*Required Fields)

 *Contact Name:

  Address:

  City/State/Zip:

  *Phone:

  Fax:

  *Email:

  Preferred contact:

Phone     Email

  Referred by:

  Type of Massage:

Deep Tissue Medical Massage Swedish Shiatsu Pre-Natal Acupressure Reiki Warm Stone Chi Nei Tsang Chair Massage

  Yoga Classes:

Private Yoga Class Group Yoga

  Preferred day of week:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  Preferred time:

a.m. p.m.

  Duration/Rates:

Half Hour One Hour One and a Half Hour Two Hour Couples Massage (two concurrent 1-1/2 hrs)

  Comments, questions: