Informed Consent of a Minor (Arrangement)

Informed Consent of a Minor

for a Client under the age of 18 years old to be treated without a Parent/Guardian present for duration of scheduled session
Name of Minor/Ward/Person*

First NameLast Name
Client's Date of Birth*

MonthDayYear
I hereby give permission (and until further notice) to Jessica N. Ferrer, LMT to provide my minor child/ward/person under my guardianship with therapeutic massage services as deemed appropriate and discussed with me to treat presenting conditions/injuries. I understand that I am financially responsible for the minor, and that all statements contained in this consent apply equally to myself and to the minor.

My child/ward/person has my permission to appear for treatment without me present and I further understand that I must make the appointments.

I will provide the Provider a valid credit card to keep on file at the scheduling of the initial appointment for this minor to be used for payment once services have been provided. With advance notice to the Provider, other payment arrangements may be made in advance of every scheduled session and it is my responsibility to communicate that with the office immediately.
Parent/Guardian Full Name*

First NameLast Name
Email*
example@example.com
Best Contact Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Signature*

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Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
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