Appointment Request Form

Appointment Request Form

Let us know how we can help you! The appointment will be ONLY be confirm after you have communicated with Dr. Karina and you both have agreed on a date.
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What date and time work best for you?
Any other specific date and time, if the above selection is not suitable.

MonthDayYear
Date
Hour MinutesAM/PM Option
what services are you interested in?*

Myofascial Release Session (manual)IASTM (instrument assisted soft tissue mobilization)In person crystal healing and chakra balancingLong-distance chakra healing and Aura cleansingVirtual Health Intuitive Reading with ReportSpirit Baby Reading
Would you like to be added to our Monday's Healing Circle Newsletter?

YesNo
Should be Empty: