All persons 12 & under are required to have a parent or guardian fill out this form
Please check all boxes below as you read through each statement *All boxes must be checked before we are able to proceed with treatment:

-You agree that you are the parent or legal guardian of the minor receiving treatment(s)
-You understand that you are required to remain at the facility for the entirety of the minor’s treatment(s)
-You will also also be required, if needed, to assist the minor in preparing for their treatment(s)
-We may also request that you remain in the treatment room to supervise all interactions between the therapist and the minor
-You agree that you have competed the intake form and have informed the therapist of any and all medical diagnoses, symptoms, medications and complaints associated with the minor receiving treatment(s)

Accuracy of Information:
I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.

Client’s Consent & Release
I have completed the intake form for the above-mentioned minor and informed the therapist of any and all relevant medical history and concerns.

I understand the scope of manual therapy and that it is not meant to diagnose, treat, or cure any conditions and is not a replacement for standard medical care.

I give permission for my minor to receive treatment(s) at Urban Massage & Wellness and agree to all of the above terms.