Self-Pay Booking

Pay out of pocket. A $25 deposit is collected at booking and applied toward your visit balance — it is not an extra fee.

HIPAA Notice: This form collects protected health information (PHI) solely for scheduling your appointment. Your information is transmitted securely and handled in full compliance with HIPAA privacy regulations. We will never sell or share your data with unauthorized third parties.

Secure & Encrypted Submission

Step 1 of 4 — Patient Information

First Name *

Last Name *

Email Address *

Phone Number *

Step 2 of 4 — Select a Service

Service *

Step 3 of 4 — Choose Date & Time

Appointment Date *

Step 4 of 4 — Review & Pay Deposit

Name —

Email —

Phone —

Service —

Date —

Time —

You will be redirected to Square to pay the $25 deposit after clicking "Reserve & Pay Deposit". Your appointment is confirmed only after payment is complete.

I understand the cancellation policy: cancellations less than 24 hours before my appointment will result in forfeiture of my $25 deposit.