Client Information Form Welcome! Twitter First Name * Last Name * Email Address * Cell Phone Number * Street Address * City State Zip * Date of Birth * In Case of Emergency Contact * Emergency Contact Number * If Client is a minor, add Responsible Party Name Responsible Party Relationship to Client Responsible Party Contact Number Welcome to Quantum Vitality! Thank you for completing the Client Information form. Before your first appointment please also review and fill out the following online forms: Welcome and Office Policies Form; Emotional Healing and Transformation - Disclaimer; Life Balance Questionnaire; Body Awareness Questionnaire; and My Thoughts and Feelings Questionnaire. Also, please review our Notice of Privacy Practices. Thank you! Please indicate which Quantum Vitality Services interest you (Check all that apply) * Quantum Neurology Emotional Healing and Transformation Performance Consulting Nutritional Consulting Chiropractic Adjustment How Did You Hear About Quantum Vitality? Please include the name of the person who referred you. Thank you.