MINOR CONSENT FORM

MINOR CONSENT FORM
Date*

MonthDayYear
Date
Patient
Parent/Guardian
Consent for Treatment

I, the undersigned, hereby authorize the licensed providers and staff of Associates Physical Therapy to evaluate and provide rehabilitation treatment to the above-named minor.
Please select the sevices below*

Physical TherapySports Performance TrainingMassage TherapyCryotherapyShockwaveDry Needling
I acknowledge that these treatments are generally safe but may involve some risks such as temporary soreness or discomfort. I have had the opportunity to ask questions about the nature and purpose of the treatment, and all my questions have been answered to my satisfaction.

Acknowledgment and Signature

By signing below, I confirm that:

I am the parent or legal guardian of the above-named minor.
I have the legal right to authorize medical treatment for this minor.
I consent to rehabilitation treatment as outlined above.
I understand I may revoke this consent at any time in writing.
Printed Name
Signature*

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