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New Client Appointment Request

First and Last Name*

Street Address*

City and State*

Zip*

Email*

Confirm Email*

Phone Number (with dashes)*

Additional Phone Number (with dashes)

Reason for appointment*

Services you would like:*

Would you like a 30 minute footbath detox session for $40*

Additional Information

How did you hear about us?*

If referred by another, who?

Please call the office when you submit this form for fastest response at 724-260-5301 (sometimes the forms get lost in cyberspace!)*

Select an option

We will be emailing you some times today, please check email, including junk mail folders*

Select an option
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