Forms

Book Mobile Reflexology

Name (first & last)

Cellphone Number:

What is the physical address where you woul like to have your reflexology session?

Is this address:

a private residence a workplace a community centre other

Day, Date, Time:

How many reflexology treatments would you like to book in for this visit?

It's just me - $85.00 Myself and 1 other person - $160.00 Myself and 2 other people - $225.00

Is this the first time you have had reflexology with The Relaxation Room?

No Yes

How will you be paying for your reflexology treatment?

Internet Banking Credit Card

Note: The Resting Space is presently only available to women, and as an addition to a treatment in The Relaxation Room.

Your First Name:

Your Last Name:

Your Email:

Your cell phone number:

Type of Stay:

Overnight after my treatment. A rest before my treatment. A rest after my treatment.

What is your preferred date and time?

If you're unsure, just give an indication that would suit you best.

Will you be bringing a pet?

Yes No

Use this space to provide additional details or ask questions.