Name *

First Name

Last Name

Phone

(###)

###

####

Event Date

MM

DD

YYYY

Cancellation Policy * *

Appointments are No Charge. However, if you need to cancel or reschedule, we request at least 24 hours of notice. Cancellations or missed appointments without 24 hour notice will result in an automatic cancellation fee of $50.00 charged to your credit card. Credit Card Information can be provided below OR over the phone from Wednesdays- Fridays from 11 am - 7 pm.

I've read the Cancellation Policy, and Understand that in the event my appointment is missed or cancelled without a 24 hour notice, I will be automatically charged a cancellation fee of $50.00 to the credit card on file. Appointments without a Credit Card on file is Not Confirmed.

Appointment request date *

Thursdays & Fridays Only Duration: 45 minutes

MM

DD

YYYY

Time *

11:15 am, 12:45 pm, 2:00 pm, 3:30 pm, 5:00 pm

Hour

Minute

Second

AM PM