Minor Consent

Minor Consent

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
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Emergency Contact*

First NameLast Name
Phone Number
Is there any additional information for the therapist to know not listed on your intake form?
4 the Luv of Massage Day Spa Terms and Conditions:

Client services and chart information are confidential.

Written authorization is required from you to release any information.
- I understand that a parent or guardian needs to be on the premise while the minor is a session.
- I have completed this consent form to the best of my knowledge.
- I understand that massage does not have the place of any physician's treatment or care.
- I understand that I may also end the session at any time if I feel uncomfortable for any reason.
- I hereby release 4 the Luv of Massage Day Spa employees, owners, representatives from all claims, costs, demands, expenses and causes of action should any condition be aggravated at any time.
By my electronic signature below, I agree that I have read the information above and have decided to give my minor consent to receive a massage at our own risk.
Signature of Parent/ Guardian

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Date *

MonthDayYear
Date
Should be Empty: