Parental Consent for Massage Therapy
Have a parent or guardian review and sign consent for the minor’s massage appointment.
Minor's Full Name
*
First Name
Last Name
Minor's Date of Birth
*
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Month
-
Day
Year
Date
Parent or Guardian's Full Name
*
First Name
Last Name
Relationship to Minor
*
Parent or Guardian's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent or Guardian's Email Address
example@example.com
Consent Statement
*
I am the parent or legal guardian of the minor named above. I consent to my child receiving massage/bodywork treatment for therapeutic purposes only. I understand that the session may include techniques such as light to moderate pressure, stretching, and other basic bodywork methods as appropriate, and I understand that the provider will use professional judgment to determine what is suitable for the minor. I acknowledge that massage/bodywork is not a substitute for medical care, diagnosis, or treatment. I confirm that I have provided accurate health information, including any relevant conditions, allergies, injuries, or concerns that may affect treatment. I understand that the minor may stop the session at any time if they feel uncomfortable, and I agree to communicate any concerns before or during the appointment. I understand that reasonable draping and privacy protocols will be followed, and I consent to the minor receiving massage/bodywork services under the provider’s professional standards and safety procedures.
Parent or Guardian's Signature
*
Date of Consent
*
-
Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: