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141 E. High Street Pottstown, PA 19464
(610) 705 - 4401

Minor Release Form

Minor Release Form

All persons under the age of 18 are required to have a parent
or guardian fill out this form.

By filling out the information below and submitting, you agree that you are the parent or legal guardian of the minor receiving treatment(s) at our facility. You understand that you are required to remain at the facility for the entirety of the minor’s treatment(s). You will also be required, if needed, to assist the minor in preparing for his/her treatment(s). We may also request that you remain in the treatment room to supervise all interactions between the therapist and the minor.
You also agree that you have completed the Intake Form and have informed the therapist of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).

I , certify that I am the parent or legal guardian of , who is years of age as of today. I have completed the Intake Form for the above-mentioned minor and informed the therapist of all relevant medical history and concerns. I understand the scope of massage 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 child to receive treatment(s) at this facility and agree to all the above terms.

Date:
Email:

Request More Info

Request More Info

We know life gets busy making it hard to visit us for a tour or open house. We’re always available to answer your questions and happy to help. Please fill out the form below and our admissions staff will email you information and follow up with you to answer any questions you may have.

By submitting this form, you are giving your consent for our admissions staff to reach you at the phone number you have provided.