Parent, Guardian or Substitute Decision Maker (S.D.M) Consent & Release Form (children and adults)

Parent, Guardian or Substitute Decision Maker (S.D.M) Consent & Release Form (children and adults)

All persons under the age of 19 and any adults 19+ who for any reason are unable to sign documents for themselves, are required to have a parent, guardian or substitute decision maker complete this form.
Name of Parent, Guardian, or Substitite Decision Maker

First NameLast Name
Name of Client Receiving the Session

First NameLast Name
Birthdate of Client (for minor children)

MonthDayYear
Date
I, name of parent or guardian or s.d.m* , certify that I am the parent, legal guardian or substitute decision maker of Client Name*.

I have completed the New Client Health Questionnaire and Consent Form and will complete all ongoing required documents for the above - mentioned client, and have informed the practitioner of all relevant medical history and concerns.

I understand that all treatments are for relaxation and stress relief purposes only, and are not meant to diagnose, treat or cure and specific condition(s), and is not a replacement for medical treatment or registered massage therapy. I give my permission for the client to receive treatment(s), and agree to all above terms.
By signing this document you agree that:
- You are the parent, legal guardian or substitute decision maker of the minor child or adult client.
- You will also be required, if needed, to assist the in preparing for his/her treatment(s).
- If needed, you will remain in the treatment room to supervise all interactions between the practitioner and the client.
- The practitioner will be notified of any changes in the health condition of the client.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: