Client Information Form Welcome! Web Site First Name * Last Name * Your Email Address * Your Date of Birth * Your Cell Phone Number * 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 download, print and sign the Informed Consent to Care and Treatment form. 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.