Consent and Acknowledgment
I hereby consent to and authorize Sevierville Massage Therapy and its licensed therapists to perform massage therapy services on my minor child.
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Parent/Guardian's First Name
Last Name
Minor's Name
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First Name
Last Name
I understand the following:Purpose of Massage Therapy: The massage is intended to promote relaxation, stress relief, or address specific muscular concerns.Voluntary Participation: My child may choose to discontinue the session at any time.Scope of Practice: Massage therapists do not diagnose or treat medical conditions and are not a substitute for medical care.Appropriate Draping: My child will remain appropriately draped at all times, and only the area being worked on will be uncovered.Privacy: A parent/guardian has the right to remain in the room during the session.Health InformationDoes the minor have any medical conditions, injuries, or allergies the therapist should be aware of?If yes, please describe: _______________________________________________________
Release of Liability: I release and hold harmless Sevierville Massage Therapy and its therapists from any claims or liabilities arising from this massage session. Signature By signing below, I certify that I am the legal parent/guardian of the minor named above and have the authority to provide this consent. Parent/Guardian Signature:
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Date
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Month
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Day
Year
Date
Phone number in case of emergency
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Please enter a valid phone number.
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