Parent Consent/Minor Release Waiver
All persons under the age of 18 are required to have a parent or guardian fill out a disclaimer form. By signing below, you are stating that you are the parent or legal guardian of the minor receiving treatment(s) at our facility. You are welcome to stay in the clinic room with your minor the entire time, or you can also check the box below if you give your minor permission to receive treatment from the practitioners. The services that we offer are not substitutes for medical advice or physician-prescribed treatment.
I, the parent or legal guardian, give permission for my child’s health information to be shared between each of my Reiki practitioners.
I permit
I do not permit
I understand the scope of a Reiki practitioner and the treatments are not meant to diagnose, treat, or cure any conditions and is not a replacement for standard medical care.
I understand.
I don't understand
I certify that I am the parent/legal guardian of the person mentioned below who is under age as of today. I give permission for my minor child to receive treatment(s) at this facility and agree to all the above terms.
I confirm and understand.
I do not understand or confirm.
I agree to fully release and hold harmless Arlene from and against any and all claims or liability of any kind or nature arising out of or in connection with my child’s session(s).
I Agree
I Disagree
Child's Name
First Name
Last Name
Parent or Legal Guardian
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
Date
-
Month
-
Day
Year
Date
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Should be Empty: