Vibroacoustic Therapy Consent Form

Coastal Wellness & Life Coaching Center

3270 Suntree Blvd STE 103A-E

MELBOURNE, FL 32940

I understand that Vibroacoustic Therapy is a gentle, sound-based approach to health and healing that can potentially assist my body in its natural ability to heal. I fully acknowledge and understand that this is accomplished using sound and vibrations. I acknowledge that long term imbalances or disease in my body sometimes requires multiple sessions to facilitate the level of relaxation needed by the body to heal itself.

I understand that Vibroacoustic Therapy is not intended to replace any currently prescribed medical treatments as ordered by my physicians, nor any other medical care I have, or may be advised to seek by them.

I understand that the practitioner will neither diagnose any medical condition, nor prescribe for any condition that I might have, nor does that practitioner make any specific claims regarding results from the sessions that I receive. I agree that it is my responsibility to consult a licensed medical practitioner for any physical or mental complaints I may have.

I understand that all client information and records are treated in a confidential manner. My experiences during these sessions are confidential subject to the usual exceptions governed by state or federal laws and regulations.

Appointment and Cancellation Policy

In our effort to provide you with the best possible service, we reserve your appointment time just for you. This guarantees your time utilizing the Vibroacoustic Therapy bed. In order to be respectful of the needs of other clients, please be courteous and call the office promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in need of treatment. If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Calling early in the day is appreciated. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely care.

We require a credit card on file to enforce our cancellation policy. This is done in fairness both to clients who would otherwise have wanted the appointment and to our staff who have prepared the session time specifically for you.

A fee will only be charged in the event:

➢ You do not show up for your appointment and do not call, or cancel within 24 hours of the appointment time- the entire appointment fee will be charged.

A reminder email or text message (your choice) will be sent a week to 24 hours before the scheduled appointment time to your designated email address or cell phone on your information form.  Please call 321-757-4015 to cancel or reschedule an appointment.

*If you are more than 20 minutes late to any appointment the appointment will be canceled and you will be charged a no-show fee unless you have called to tell me you are running late.

I, or my representative(s), agree to fully release and hold harmless Coastal Wellness and Life Coaching Center and practitioners therein from and against any and all claims or liability of whatsoever kind or nature arising out of, or in connection with, my session (s).

By signing this form I give my consent to receive or my child to receive Vibracoustic Therapy at Coastal Wellness and Life Coaching Center.