New Client Request Form

New Client Request Form

This form allows you the opportunity to request a Massage Therapy appointment with Jane Neldon, LMT. Currently, I am only accepting new clients by direct referral from a current client or medical practitioner. Same day appointments are not available.
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
What day(s) of the week are you available for a massage therapy appointment? *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday No Preference
What times during the day generally work best for scheduling a massage therapy appointment? *

10am-12noon 11:30am-1pm 1pm-3pm 3pm-5pm No Preference
If you looked at my scheduling website and saw a specific time that you're interested in, please list the date and time here:
Preferred Session Length *
90 minute massages are currently unavailable.
What are your goals for this massage session? (select all that apply) *

Relax & De-stress Workout Recovery Relief from work-related aches/pains Injury Relief Relief from pregnancy discomforts Relief from cancer treatment side effects Maintain overall wellness
Who referred you to Jane Neldon, LMT? *
If you are looking to redeem a gift certificate, please list the certificate's code number:
Any other information, comments, or questions?
Jane will contact you directly to confirm an appointment time and date.

If you do not receive an official confirmation, your appointment is not complete.

Additional information or questions can be sent to commonwealthmt@gmail.com

During this era of Covid-19 concerns, face masks are required by both myself and my clients throughout the entirety of the massage appointment. This is by official mandate from Governor Northam and is in place for the safety of us both.

No mask = no massage. No exceptions.
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