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Massage Payment Plan Agreement
For 12 massage sessions
LMT Brian Keene, Inside Shapiro Family Chiropractic
2121 S. Oneida St., Suite #420, Denver Co 80224
or SMART Bodywork® Mobile Massage
* Indicates required question
Email
*
Your email
First & Last Name
*
Your answer
Address
*
Your answer
Address #2
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Zip
*
Your answer
Phone
*
Your answer
Choose a Session Type
*
60 minutes $85
75 Minutes $105
90 minute $125
One of the Amazing Heat Therapy Treatment's (please identify in notes below) - in-office only
Other:
Payment Plan Terms
*
18 months
12 months
Massage Location
*
Brian Keene LMT Massage Office 2121 S. Oneida St, Suite #420, Denver Co 80224
SMART Bodywork® Mobile Massage (add $25 per/session)
If you chose Heat Therapy Treatment, please tell us which one:
Your answer
I would like to include tip for my therapist in this payment plan agreement. I would like to tip:
*
$300
$250
$200
Other:
Required
I am submitting a formal agreement to create a payment plan for massage services with SMART Bodywork and massage therapist Brian Keene LMT in Denver, Co.
*
Yes
No
I understand I may request gift certificates and share my massage sessions with friends and family in the agreement and/or by submitting an email in advance to
briankeenelmt@smartbodywork.com
Subject: Share My Massage
*
Yes
No
Send me a copy of my responses.
Submit
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