Name *

First Name

Last Name

Phone *

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Date *

MM

DD

YYYY

Client Agreement *

It is my choice to receive treatment from Vital Massage & Bodywork. I am aware of the benefits and risks of my treatment and give my consent to the practitioner. I understand that there is no implied or stated guarantee of success or the effectiveness of individual techniques or series of appointments. I acknowledge that massage/ bodywork/ manual therapy is not a substitute for other forms of medical care, medical examination, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information may be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. I understand and consent to my contact information being collected and used for marketing and communication purposes by Vital Massage & Bodywork. I understand that I will have the ability to opt out of receiving marketing communications at any time. I understand that the staff of Vital Massage & Bodywork reserve the right to end the session and charge 100% of the service if they feel threatened or unsafe.

I accept and agree to the above terms and conditions.