Welcome To Just A Glimpse. Please take a moment to fill out the intake form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you experiencing any symptoms of COVID now or in the past 14 days? (fever, chills, sore throat or vomiting
*
yes
no
Have you been around anyone in the past 14 days that was diagnosed with COVID and/or the flu
*
Please Select
Yes
No
Do you have any other serious medical conditions (heart conditions, blood clots, or circulatory issues that would prevent or limit the services that we provide , if so please provide information below
*
Please Select
Yes
No
blanks
Are you pregnant? If no please skip next question
*
Please Select
yes
no
If answered yes, how far along are you?
Please Select
First trimester (conception-12wks)
Second trimester (13-27wks)
Third trimester (28-40wks)
N/A
Any skin conditions or health concerns that may prevent you from receiving services? (open sores, cuts rashes, etc)
*
Please Select
yes, please explain......
no
If you answered yes to the above question,
Please list any areas that you may need us to concentrate on a little more?
Appointment
What is the duration of the service you are trying to get and will there be add ons?
30 min target areas
60min relaxing/therapeutic
75min relaxing/therapeutic
90min relaxing/therapeutic
hot stone/cupping add on
prenatal /varied stretching
Do you have any areas you want avoided? ex feet, glutes-rear end area, pectoralis-upper chest area a little under the collarbone(clavicle)
*
what is your prefered pressure?, if this is your first massage please select "other"
light
Light-medium
medium
Med-firm
Firm
Other
Please be aware of the $35 deposit that is required to secure your services you will have 15mins after booking to send deposit! I do understand that life happens and we do get a little busy, just communicate with us and we can work something out!
My Products
*
prev
next
( X )
deposit for services
service deposit will be deducted from final total
$
35.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
ACH Bank Transfer
Should be Empty: