All Clients will be expected to read and sign this
form prior to treatment.
Client-Informed Consent Form.
Massage Therapy Treatments & Multi-Treatment Package Policies.
I______________________________________, have purchased a Massage Therapy
Package from (Print your name here.) Massage Therapist Anthony P Pauly Jr.
The number of the agreed upon sessions is ________________________________.
The price paid is ______________________________________________________.
I understand that the sale is final at the time of the purchase and that future prices are
subject to change and will be posted on the providers website
www.gatheringofbutterflies.com .
I understand that all purchases are final and that should I, as the client, terminate the use
of the services purchased, any and all funds that are applied to unused massage
treatments are not refundable.
I understand that if any refund is offered, it will be offered solely
at the discretion of the provider.
Any unused portion of a purchase may be transferred into gift certificates.
I understand that all price offers are posted on the website and all
offers are subject to change at any time.
I understand that package offers and first time client discounts are available to first time
clients at the time of the first appointment. Any other discounts will be offered at the
discretion of the provider and will be posted on the website.
The price at the time of purchase will remain valid until all massages purchased on that
date are used in full. After the date of the last appointment, if the price posted on the
website has changed, I understand that as the client, I am expected to pay the newly
posted price.
After you have read this, please initial on the above line.
I also understand and agree that all appointments will be made at least 24 hours in
advance, based on the availability of the practitioner.
It is my responsibility as the client to contact Anthony to set up an appointment time that
is mutually accommodating.
I understand that Anthony is the only person that can finalize an appointment and that no
appointments made by a third party will be guaranteed.
I also agree that if I fail to notify Anthony 24 hours in advance of a cancellation,
there will be a $25 fee charged for the missed appointment.
I understand that this fee must be paid prior to any further appointments being made.
I understand that any funds that are not redeemable because of checks that bounce will
be required to be paid in full with an additional $25 fee. This must be paid in a US Postal
Money Order. Should a check bounce, I understand that continuation of the services
offered will be entirely at the discretion of the practitioner.
No guarantee of refunds will be offered.
I understand that if I, as the client, during the course of any of the therapy sessions,
behave in a manner that is inappropriate (of a sexual, harassing, or violent nature), the
session may be terminated prematurely by the practitioner and no refund will be offered
regardless of the number of sessions completed.
I, as the client, have disclosed any and all medical issues and conditions to the
practitioner.
I will not hold the practitioner accountable for any injuries resulting from failing,
intentionally or unintentionally, to communicate and disclose any and all medical issues
and conditions.
I also understand that should the practitioner be made aware of a medical condition of
mine where Massage Therapy is contraindicated or not recommended after the
appointment has been set or while it is in progress, that no guarantee of refund will be
offered.
Should Massage Therapy services be refused under these circumstances,
I understand that I, as the client, must receive a written form of permission from a
licensed Medical Doctor attesting to the fact that Massage Therapy Treatment is safe for
me, as the client. This must be provided to the practitioner prior to any continuation
of services.
I___________________________________________ have read, understand and agree to
all of the policies in this client-informed consent form.
_________________________________________________________________________
Client Signature and date. Practitioner Signature and date.
Date of appointments starting ________________________________________________
Client please initial next to each entry. _________________________________________________________________________
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