Q1 2024 Request to Book

Availability Form - Q1 2024

We will check your availability form against our upcoming openings and contact you when we have appropriate treatment times.
Name*

First NameLast Name
Visit History*
Phone Number
Format: (000) 000-0000.
Email*
example@example.com
Gender Identity

MaleFemaleNon Binary
Prefer to specify:
Pronouns

She/HerHim/HisThey/ThemOther
Please note our hours vary slightly from week to week, but we are generally open from 8AM-2PM
Indicate Day Availability (we are closed Wednesdays, weekends and holidays)

MondayTuesdayThursdayFriday
Indicate if there is a specific time that works best for you, or if you prefer "Early Morning" (8-10AM), "Late Morning" (10-12) or "Early Afternoon" (12-2PM)
If you prefer to list specific dates of availability, please do so here:
Please include "black out dates"/vacation etc if applicable.
Select Treatment Frequency Preferences*
Select Applicable Insurance Coverage

Pacific Blue CrossManulifeCanada LifeOtherNone/Private Pay
Select Treatment Goals

Injury RehabTreatment of headaches/migrainesPreventative/MaintenanceAnxiety Reduction/Stress ManagementGeneral tensionImprove flexibilityImprove sleep qualityOther
Is there a specific injury or area of of concern that you are seeking treatment for?*
*

I understand and acknowledge that masks are required in the studio, and I am expected to provide my own.
*

I understand and acknowledge that a strict 24-hour cancellation policy is in place and any cancellations made with less than 24 hours' notice or failure to attend a scheduled appointment will be subject to the standard cancellation fee.
Should be Empty:

Availability Form - Q1 2024