Pre-pay / Post-pay below!
Kindly note - this is NOT an automated form; our front desk will reach out to acknowledge receipt of your purchase. You can also pay your practitioner directly at time of service.
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
What is this payment for?
*
Pre-pay for future session(s)
Payment for recent session
Late cancellation or missed appointment
Other
Please indicate the date & time of the appointment(s) you wish to pay for, the client's name (if not you), and the therapist's name.
*
Select your item(s) below! Flat amount selections & gratuity options are below our service options.
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( X )
30-minute session
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
45-minute session
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
60-minute session
$
120.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
75-minute session
$
140.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
90-minute session
$
160.00
Quantity
1
2
3
4
5
6
7
8
9
10
SPECIALTY UPGRADE
$
25.00
Ashiatsu, Hot Stone, or PreNatal, treatments (for 60+minute sessions only)
Quantity
1
2
3
4
5
6
7
8
9
10
Type of upgrade
Ashiatsu
Hot Stone
PreNatal
Not sure/Mix & Match
Item subtotal:
$
0.00
Flat amount
$
100.00
Flat amount
$
250.00
Flat amount
$
500.00
Flat amount
$
750.00
Flat amount
$
1,000.00
Gratuity option 1
$
15.00
Tips are appreciated, but never expected! You may also tip your therapist directly after your treatment.
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Item subtotal:
$
0.00
Gratuity option 2
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Item subtotal:
$
0.00
Gratuity option 3
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Item subtotal:
$
0.00
Gratuity option 4
$
30.00
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Item subtotal:
$
0.00
Gratuity Option 5
$
35.00
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Gratuity Option 6
$
40.00
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total
$
0.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Submit
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