Mobile Massage Form

Mobile Massage Form

804-837-4292 | vhm.massage@gmail.com | www.vitalityhealthmassage.com
Policies:

Please visit our website at: www.vitalityhealthmassage.com to review our policies. By completing this form you agree to all of our policies. We require a 48 hour notice if your appointment must be canceled or rescheduled. We do not offer any refunds if you fail to provide a 48 hour notice.
I have read, understand and agree with this policy.
Important Please Read:

PAYMENTS: All payments are final with no refunds. Due to the travel distances, set up, and clean up time required for a mobile massage appointment, I will call you to schedule your mobile massage appointment with you. *PLEASE DO NOT SCHEDULE MOBILE MASSAGE APPOINTMENTS ONLINE*. SCHEDULING FOR OTHERS: If you are scheduling an appointment for someone other than yourself such as a family member or spouse, they will be considered the "Client." Please list their information in sections that say "Client." We will email an intake form to the email address provided in the "Client" sections. We respect the privacy of our clients and we will not discuss any of their health or private information with anyone other than the client. This may mean that the spouse or person scheduling the massage for the client may be required to provide a written consent or a signed and notarized power of attorney.
Contact Person:

This is the person who is scheduling the massage for someone else. I will need your information so that I can contact you for any scheduling issues or questions that I may have. Please fill out all selections below that say "Contact Person." If you are not scheduling a massage for someone else, you may put NA in the boxes of this section.
Todays Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full Name Of Contact Person (Person scheduling the massage for someone else):

First NameLast Name
Contact Person's Address: This will be your address. See the address section below to let me know what address I will need to travel to for the massage.

Street Address

Apartment Number Or Suite Number

CityState / Province

Postal / Zip Code
Phone Number Of Contact Person (Person scheduling the massage for someone else):

Area CodePhone Number
Email Address Of Contact Person (Person scheduling the massage for someone else):
example@example.com
Client Information:

This section is for the person receiving the massage. Important: I will be emailing them an intake form which will need to be completed before we do the massage. Please only put their information on the intake form and do not put your telephone, address, or your email address on the form. The information must be the clients information. Thank you.
Address Of Where The Massage Will Take Place: Please make sure you enter the full address with apartment number. *We will only travel if you are located at a residence and will not travel to hotel rooms*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Full Name Of Client (Person receiving the massage):

First NameLast Name
Email Address Of Client (Person receiving the massage):
example@example.com
Phone Number Of Client (Person receiving the massage), If the massage is for you, please put your telephone number here

Area CodePhone Number
Address Of Client (Person receiving the massage):Please make sure you enter the full address with apartment number. *We will only travel if you are located at a residence and will not travel to hotel rooms*

Street Address

Apartment Number or Suite Number

CityState / Province

Postal / Zip Code
Please leave any comments or questions here for the therapist? Please let us know if you are seeking massage for relaxation, a specific pain issue, recovery from a injury, mobility/flexibility, stress/anxiety?

Mobile Massage - Please make a selection below.

Mobile Massage Service Area Policy
Vitality Health Massage provides mobile massage services only within
- Chesterfield County
- Chester, Goochland County
- Hanover County, Henrico County
- Powhatan County
- City of Richmond.
If your location is outside these service areas, please do not schedule a mobile massage appointment. Mobile massage appointments must also be located within 25 miles of our office at 1210 Sycamore Square Drive, Midlothian, VA 23113.

Appointments outside the 25-mile service radius may be canceled.
I agree and understand this policy.

Topics or policies to review with clients.

Rows	Yes I have read and agree to your policies
Our Website: https://www.vitalityhealthmassage.com
Vitality Health Massage - Office Policy https://www.vitalityhealthmassage.com/officepolicy
Vitality Health Massage - Privacy Statement https://www.vitalityhealthmassage.com/privacystatement

Should be Empty:

Mobile Massage Form

Policies:

Important Please Read:

Contact Person:

Client Information:

Mobile Massage - Please make a selection below. *

Credit Card

Mobile Massage Service Area Policy

Mobile Massage - Please make a selection below.