Appointment Request Form

Appointment Request Form

Let me help relax & heal you!
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
What date and time work best for you? Mon - Sun 1p to 5p
Any other specific date and time, if the above selection is not suitable.

MonthDayYear
Date
Hour MinutesAM/PM Option
What type of Reiki session did you want to book? Sessions are 60 minutes.
What are you looking to get out of your reiki service?
Do you have any medical issues that I should be made of aware of?
Please list any allergies below and tea types that you enjoy for the tea ceremony that happens during your session. Essential oils are used during your session. (If none leave blank.)
I acknowledge that by signing this form that I acknowledge the risks that may arise if I don't follow the aftercare instructions provided before the session started. I had the chance to ask about any questions, and my questions were answered to my satisfaction beforehand. I have reviewed and I approve of the material provided to me. I accept full responsibility of having this reiki session done.
Signature
Date signed*
Would you like to be notified about promotional services?
Should be Empty: