Mobile Massage Form
804-837-4292 | vhm.massage@gmail.com | www.vhm.massagetherapy.com
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:
*
-
Month
-
Day
Year
Date
Full Name Of Contact Person (Person scheduling the massage for someone else):
*
First Name
Last 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.
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Street Address
Apartment Number Or Suite Number
City
State / Province
Postal / Zip Code
Phone Number Of Contact Person (Person scheduling the massage for someone else):
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Area Code
Phone 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 will only travel if you are located at a residence and will not travel to hotel rooms*
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Full Name Of Client (Person receiving the massage): :
*
First Name
Last 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 Code
Phone Number
Address Of Client (Person receiving the massage):Please make sure you enter the full address with apartment number. *We will will only travel if you are located at a residence and will not travel to hotel rooms*
*
Street Address
Apartment Number or Suite Number
City
State / 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.
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Categories:
All
All
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next
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Mobile Massage- 60 Minute Session
$120.00
$
120.00
Let us come to you! We can meet you at your home, apartment, or business. (Note: We will not meet at a hotel or motel)
Quantity
1
2
3
4
5
6
7
8
9
10
Mobile Massage- 90 Minute Session
$165.00
$
165.00
Let us come to you! We can meet you at your home, apartment, or business. (Note: We will not meet at a hotel or motel)
Quantity
1
2
3
4
5
6
7
8
9
10
Mobile Massage- 120 Minute Session
$165.00
$
165.00
Let us come to you! We can meet you at your home, apartment, or business. (Note: We will not meet at a hotel or motel)
Quantity
1
2
3
4
5
6
7
8
9
10
*CBD MASSAGE OIL- 1500 MG
$10.00
$
10.00
Take your massage to the next level with CBD Massage Oil. Sooth both your mind and sore muscles. Learn More: www.vitalityhealthmassage.com/cbdmassage
Quantity
1
2
3
4
5
6
7
8
9
10
Scented Massage Creme With Arnica
$5.00
$
5.00
Arnica helps to reduce inflammatory pain when applied topically. Typically it's used for the pain and swelling associated with bruises, sprains, pulls, muscle aches, and even arthritis, since it helps to boost circulation and speed up the healing process.
Choose Your Favorite
Geranium Sage
Green Tea Mint
Tangerine Basil
Lavender
Vanilla Lemongrass
Polar Ice Cream
Quantity
60 Minute Massage- 15% - Tip For Your Therapist
$18.00
$
18.00
You may add a tip for your massage therapist here.
60 Minute Massage- 20%- Tip For Your Therapist
$24.00
$
24.00
60 Minute Massage- 25%- Tip For Your Therapist
$30.00
$
30.00
90 Minute Massage- 15%- Tip For Your Therapist
$24.75
$
24.75
90 Minute Massage- 20%- Tip For Your Therapist
$33.00
$
33.00
120 Minute Massage- 15%- Tip For Your Therapist
$33.00
$
33.00
120 Minute Massage- 20%- Tip For Your Therapist
$44.00
$
44.00
120 Minute Massage- 25%- Tip For Your Therapist
$55.00
$
55.00
Total
$0.00
$
0.00
Credit Card
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.
Topics or policies to review with clients.
*
Rows
Yes I have read and agree to your policies
Our Website:
https://www.vitalityhealthmassage.com
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https://www.vitalityhealthmassage.com/officepolicy
Vitality Health Massage - Covid 19 Statement
https://www.vitalityhealthmassage.com/covid-19
Vitality Health Massage - Privacy Statement
https://www.vitalityhealthmassage.com/privacystatement
Vitality Health Massage - FAQ
https://www.vitalityhealthmassage.com/faq
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