Energy Healing Form | Halo Chiropractic

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CALL US TO BOOK

Halo Services Form

First name

Last name

Email

Address

Phone

Which service are you interested in?

Chiropracttic

Cold Laser

Massage

Acupuncture

X-Ray

Nutrition Counseling

Date of Birth

Have you any of these services before?

Yes

No

Are you sensitive to fragrances?

Yes

No

Emergency Contact

Phone

Relation

Session Duration

60 Min Massage

90 Min Massage

75 Min Acupuncture

90 Min Reiki

60 Min Akashic Reading

What brings you to Halo?

How did you hear about us?

To reserve the appointment request, we require a card on file. Halo has a 24 hour cancellation policy. You will only be charged in the case of a no call or no show. You will recieve a 24 hour text in advance. *I accept terms & conditions*

Card Number

Expiration Date

Thanks for submitting. We have sent you an email! A Halo representative will call to schedule your appointment soon!

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