Table Massage Request Form
We provide 5 Star Massages that straight to your location.

Mobile Massage Rates from $125/ 60 minute and $165/ 90 minute
Hotel Rates from $150/ 60 minute and $200/90 minute
Weekend/ Holiday Rates from $150/60 minute and $185/ 90 minute

*Weekend rates begin on Friday at 6pm-Sunday at 9pm

* Rates may increase depending upon type of massage and parking fees
Sign in to Google to save your progress. Learn more
Let's get some info
Are you *
Your Name *
If requesting a massage for someone else, what is their name?
Your Contact Number *
Your Email Address *
How can we contact you?  (Check all that apply) *
Required
Massage Service Location (Complete Address: Street, City, Zip Code) *
Preferred Date *
MM
/
DD
/
YYYY
Preferred Time *
Time
:
Where would you like to receive your massage? *
Where do we park? Please provide as much detail as possible. ie: Building names, gate codes, guests parking (Please note: you need to take care of parking, valet, toll roads) *
Mobile Massage (From $125/ 60 min and $165/90 min)
Our licensed and insured Wellness Providers have high end standards to meet your professional massage needs. Please note: pricing may increase depending upon location, parking, or tolls. We are taking all the precautions to help prevent the spread of COVID-19. All wellness providers will be wearing masks and all equipment will be sanitized prior to  your appointment.
What kind of massage would you like? *
What Service are you looking for? (Pricing may increase depending upon service and location)
Clear selection
Choosing your Wellness Provider
Clear selection
Do you have any pets at home? If so, what kind of pet do you  have?
Do you have a Gift Card?
Please provide your Gift Card Number
Comments
How did you find out about us?
Appointment Confirmation
Thank you for your inquiry and we are looking forward to working with you. To confirm your appointment, we need completed health forms, a signed service agreement, and pre-payment via invoice.
I understand that once an appointment is confirmed, a health and environment form must be completed PER client. *
If you are having trouble with this form or have questions or concerns, please call us at: 888-540-1165
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy