New customer Repeat customer

Name (Required)

email (Required)

tel (Required)

Location of use (Address or Nearest Station)
If using a hotel or your own home, please provide the room number

Desired date of use (Required)

Start time(Required)10:0010:3011:0011:3012:0012:3013:0013:3014:0014:3015:0015:3016:0016:3017:0017:3018:0018:3019:0019:3020:0020:3021:0021:3022:0022:3023:0023:3024:0024:301:001:302:002:303:003:304:004:305:00

Preferred course(Required)—Please select from the following options—EXY Platinum CourseEXY Hybrid CourseEXY Date Course

Preferred time(Required)Trial 60 minutes90 minutes100 minutes120 minutes150 minutes180 minutes210 minutes300 minutes

Preferred options(If none, please write 'none')

Preferred therapist (If no preference, please write 'none')

If you have any other preferences, please let us know.

How did you hear about our store?

Age

Experience in female-oriented establishments
Yes No

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