Parental Consent for Treatment of a Minor | Holistic Health Associates

Parental Consent for Treatment of a Minor without Adult Present in Treatment Room
We require a Parent/Guardian present at the patient’s first consultation AND the first in-office appointment for the treatment of any minor. This form represents the option for the consent to treat a minor without an adult present in the treatment room after the initial appointments.
Date
Month
Day
Year
Printed Patient/Minor's Name:
First Last
Patient/Minor's DOB:
Month
Day
Year
Parent/Legal Guardian Emergency Phone Number:
By signing this document below, as the parent/legal guardian the minor listed above:
- I give full permission(s) for the minor listed above to receive Acupuncture, Massage, Reiki and/or Herbal Services at Holistic Health Associates without my presence in the treatment room. I confirm that I have received, read and understand all information I have received on all company forms regarding the office’s policies for this treatment or service and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree to supervise any home care that is recommended as a result of the treatment.
- I do not provide my consent for my child to be treated for acupuncture if I am not present in the treatment room
Signature of Patient, Legal Representative, or Parent/Guardian
Your Name
Your Name
Your Name
Date
Month
Day
Year
Parent/Legal Guardian Name:
First Last
Relationship to Patient

Parental Consent for Treatment of a Minor without Adult Present in Treatment Room