Parent/Guardian Permission Form

Client Information
* Denotes a required field.
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Phone Number
Parent/Guardian Phone Number
Address
Address
Minor's Name *
Minor's Name
Minor's Date of Birth
Minor's Date of Birth
Please Read the Following & Sign Below: *
I acknowledge that the herein child or young person is under the age of 18, and the signed statement below acknowledges my authorization to Therapeutic Kneads to administer the recommended treatment by assigned therapist.
Your electronic signature verifies that you have read and agree to our terms of service.
Date of Review and Signing
Date of Review and Signing