First Name *

Last Name *

Your E-mail Address*

Address

City

State ---ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code

Home Phone (555-555-5555)

Work Phone (555-555-5555)

Cell Phone * (555-555-5555)

Emergency Contact First & Last Name *

Emergency Contact Phone * (555-555-5555)

Emergency Contact E-mail *

Date of Birth

Select Gender* ---FemaleMale

Number of Children*

Profession

Current Physical Problems*

Previous Physical Problems

Surgeries

Medications

Type of Physical Activity Done 

Frequency of Physical Activity ---DailyWeeklyMonthly

Have you ever had a Thai Massage before? ---YesNo

How did you hear about Ananda's Thai Yoga Massage? *

Length of Session * ---$130 — 1 hour Thai massage session$155 — 1¼ hours Thai massage session$185 — 1½ hours Thai massage session$250 — 2 hours Thai massage session

Add Hot Herbal Compress? Yes, add a Hot Herbal Compress to my massage ($20)
Hot herbal compress work not available for 1 hour treatments

Session dates. (List some dates and times that will work for you).

Comments or Questions

 
* I understand that the courtesy of at least 24 hours notice to cancel or reschedule my appointment is necessary, and that failure to comply will result in the full charge.
 

* I understand that the time scheduled for my appointment is set aside just for me, and that if I am late, that is my loss of time at the appointment.