CLIENT #
( For Office Use Only )
All persons under the age of 18 are required to have a parent or guardian fill out this form.
By signing below, you are certifying that you are the parent or legal guardian of the minor receiving massage therapy treatment(s).
You also understand that you will required to remain at the facility for the entirety of the minor’s treatment(s), and/or that you will required to assist the minor in preparing for his/her treatment(s), and/or that we will also request that you remain in the treatment room to supervise all interactions between the therapist and minor.
You also agree that you have informed the massage therapist about all relevant medical history, symptoms, medications, and/or concerns associated with this minor.
I , certify that I am the parent or legal guardian of , who is years of age. I understand the scope of massage therapy and that it is not meant to diagnose, treat, or cure any conditions and is not a replacement for standard medical care. I give permission for my minor child to receive treatment(s) at this facility and agree to all the above terms.
Signature: Clear
Date:
