Mobile Service Request Form

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

What mobile services are you interested in? (select all that apply) *

Infusions

Botox

How many individuals will receive treatment? *

How many people are you expecting? *

What kind of event are you interested in hosting? *

Note- Mobile services for 5 or more people is considered a private event! For in-home, non-corporate private events, the host will receive half-off their treatments.

Business Name/Type (If Applicable)

When are you wanting to receive treatment? *

Date Request (date is not guaranteed, based on availability) *

What is your date range? *

I agree to terms & conditions provided by the Spa Sláinte Infusion & Wellness Lounge. By entering your phone number, you are agreeing to receive text messages from us. Message & data rates may apply. Message frequency may vary. Reply HELP for more information. You can reply STOP or UNSUBSCRIBE to opt-out. See our privacy policy for more details.