Q3 2024 Request to Book

Availability Form - Q3 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
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 9AM-2PM
Treatment Length

30 minutes45 minutes60 minutesOther
Indicate Day Availability (we are closed Wednesdays, weekends and holidays)

MondayTuesdayThursdayFriday
Indicate if there is a specific window of time that works best for you:
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.
Should be Empty:

Availability Form - Q3 2024