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Consent Form
Consent to Treat a Minor
Pregnancy Consent Form
Home
Book your session
Services & Prices
Contact & Locations
A Typical Session
About Reflexology
Forms
Consent Form
Consent to Treat a Minor
Pregnancy Consent Form
Walk in, Float out !
Name of Child:
*
First Name
Last Name
Name of Parent:
*
First Name
Last Name
Child's Date of Birth:
*
MM
DD
YYYY
*
Male
Female
Address
*
Parent's Phone Number:
*
Please state any allergies, if none state 'none':
*
By signing below I hereby authorise the certified massage therapist to administer massage therapy on my child
I also approve of any future treatment sessions
Date
*
MM
DD
YYYY
Printed name of parent/guardian:
*
By submitting this form you are agreeing to our terms and conditions (you can find the T&Cs page link at the bottom of our site)
Thank you!
