Please provide the following contact information:

Name
Street Address
City		State	Zip
Work Ph		Home Ph
E-mail
Date Preferred	please specify day of week and date	Type of Massage	Swedish/Relaxation Therapeutic Hot Stone Pregnancy Other
Time Preferred		Length	1 hr   1 1/2 hr
Have you ever had a Massage before?  Yes   No

Any special instructions or needs you may want us to know about:

Someone will contact you shortly to confirm your appointment.  Please do not take this form as a confirmation until you hear from us.  Occasionally there are scheduling conflicts, however we will do our best to make your time work for you.