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All persons under the age of 18 are required to have a parent or legal guardian fill out this form (unless legally emancipated).

By signing below you agree that you are the parent or legal guardian of the minor receiving treatment(s) at Anjou Spa. You will also be required, if needed, to assist the minor in preparing for his/her treatment(s). For children 14 - 16 years of age, a parent or legal guardian must be present in the room at the time of service. The minor will be paired with a therapist of the same gender.

You agree that you have completed 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). You also agree that you are financially responsible for the minor and that you must schedule all appointments on their behalf.

 

Please select who will be receiving a service...
Minor
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
I certify that I am 17 years of age or older
First Client's Signature*
Parent or Guardian's Email Address

Email
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A signed copy of this waiver will be sent to the email address you provide.
I certify that I am a parent or legal guardian. 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 massage therapy and esthetics 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 Anjou Spa and agree to all the above terms.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 17 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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