NAME:

PHONE:

EMAIL:

ADDRESS:

CITY:

PROVINCE:

POSTAL CODE:

PREFERRED DATE (mm/dd/yyyy):

TIME  (First choice):  

TIME  (Second choice): 

SPA/SALON PERSONNEL:
OR      RECOMMEND

SERVICE REQUESTED:

COMMENTS:

Is this your first visit to Sapphira Spa
and Beauty Salon?
YES   NO

How did you hear about us?
WEB    WORD OF MOUTH    OTHER

How did you hear about us?
WEB    WORD OF MOUTH
OTHER