All information is confidential and not shared with anyone. We are in the process of
updating our computer and we will not send you any junk mail!!
First Name: ________________________ Middle Initial: ________ Last Name: ____________________________
Address: ______________________________________ City: __________________ State: ______ Zip: __________
Home Phone: ___________________ Business Phone: _____________________ Cell Phone: __________________
Please tell us how you would like to receive appointment confirmations: By Home Phone _______
By Business Phone: ________ By Cell Phone: _______ By Email: ________
Are you interested in Online Booking?: š Yes š No If so, you must provide an email address to receive your
login ID and password. Email address:__________________________________________
Are you interested in receiving discounts related to special events in your life? If so, please provide the following:
Email address:__________________________________________
Birthday (MM/DD/YYYY) ____/____/_______ Anniversary (MM/DD/YYYY): ____/____/______
Profession: _______________________ How did you hear about us? ____________________________
What is your favorite radio station? __________ What is your favorite TV Station? _______________