Minor Consent Form

Minor Consent Form

Parent and/or guardian consent to treat his or her minor child with services being provided by Body By Bemilly.
Patient Information
Minor Child's Name*

First NameLast Name
Minor Child's Birth Date*

MonthDayYear
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Relationship to Minor
Parent E-mail
example@example.com
Parent's Phone Number*
Service Details
Service(s) to be provided
Date of Service

MonthDayYear
Date
Consent and Agreement
I, blanks , the undersigned, certify that I am the parent/guardian of the minor named above. I hereby give my consent for Body By Bemilly to provide the services specified above to my minor child. I acknowledge and agree to the following:
1. Presence Requirement: I understand that I must be present during all consultations and treatments, and I agree to remain on-site throughout the duration of each appointment.
2. Understanding of Services: I have been informed about the nature of the services to be provided and understand the potential benefits and risks involved.
3. Health Information: I have disclosed all relevant health information about my minor child to the therapist/provider, including any allergies, medical conditions, or current medications.
4. Compliance: I agree to ensure that my minor child follows all pre- and post-treatment instructions provided by Body by Bemilly and the attending therapist/provider.
5. Liability Release: I release Body by Bemilly, its staff, and therapists from any liability for any adverse effects or complications that may arise from the provided services, except in cases of gross negligence or misconduct.
6. Verification: I understand that proof of age and identification for both myself and my minor child will be required at the time of the appointment.
Today's Date*

MonthDayYear
Date
Parent Signature*

Clear
Thank you for your time and business. Have a wonderful day and enjoy your massage.
Should be Empty:

Minor Consent Form

Patient Information

Parent/Guardian Information

Service Details

Consent and Agreement