Name *

First Name

Last Name

Phone *

(###)

###

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Gender:

Female

Male

Type of Massage:

Relaxation

Deep Work

Craniosacral Therapy

Sports Massage

Prenatal / Postpartum

Shiatsu

Traditional Thai

Acupressure and Tui Na

Manual Lymphatic Drainage (MLD)

Wellness Service:

Health + Fitness Coaching

Personal Training

Psychotherapy

Sound Healing

Post-Rehabilitative Breast Cancer Exercise training

Corrective Exercise

Scar Work & Massage Post-Surgery

Oncology Massage

Oncology Exercise

Functional Fitness

Cupping

Graston

Reiki

Restorative Room

Other - Please share more details in the Message section below

Length of session: *

60 Minutes

75 Minutes

90 Minutes

Day of Massage Session Requested (Check all that apply): *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What time would you like your massage? *

Morning (9am-12pm)

Afternoon (12pm-4pm)

Evening (4pm-7pm)

Anytime

Is this your first visit to KUA Wellness? *

First Time

Returning Client

How did you hear about us?

Family / Friend

Google Search

NextDoor

Facebook

Other (Please specify below)

Are you redeeming a physical gift card? *

Yes

No