Minor Consent

All information is held in the strictest confidence. At no given point this information is disclosed or shared without client’s written consent.

You may choose to skip answering any non-require question you feel impinges on personal information you do not wish to disclose.

Minor Consent Form

Fields marked with an * are required

Guidelines:• Minors (all clients under the age of 18 – unless otherwise emancipated) can only receive massage with written parental/legal guardian consent. • In collaboration with the consenting adult and child, the massage therapist will assist in establishing goals for the session(s). • For clients age 13 and under, the parent/guardian must always be present in the treatment room.

For clients age 14-17 if both client and parent/guardian are comfortable with the child being in the session room by themselves, please check the box below

• Otherwise, parent/guardian should be in the treatment room during each session. Once a comfortable therapeutic relationship has been established and the massage therapist, child and parent are comfortable the parent/legal guardian does not have to be present in the room. • Appropriate draping will be always used during the massage, only areas being massaged are uncovered.

am the parent/legal guardian of

I have read the above information and give permission for my child, to receive massage therapy from _Daniel Marquez_ LMT_.

SIGNATURE (Please type your full name) *