Wellness Registration

First Name

Last Name

Address (Line 1)

Address (Line 2)

City

State

Zip

Phone

lpphheazbz35

Emergency Contact (Name and Phone Number)

Click here to download the EDGE Wellness Waiver

Please complete this form and bring it with you to your first session!

Are you an SMC Employee?

If yes, you will receive a half-price discount!

Payment Option

Cardholder Name

Credit Card #

Expiration Date

Security Code

Billing Zip Code

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

EDGE Wellness Registration