Schedule Appointment with Polished By Koya, LLC

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First Name *

Last Name *

Phone *

Your E-Mail Address *

Notes to Business (your address or any special notes about your order)

Item	Quantity	Total
Monthly VIP Membership	x $25.00	$25.00 per month
Total: $25.00

I will provide my Mailing Address and Birthdate in the note section above