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* 1. Name of Client

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* 2. Email Address:

By submitting this form, I understand that I am accepting the terms listed.

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* 3. I consent to this activity/procedure.

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* 4. Enter date

Date

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* 5. Check if client is a minor & will be receiving chemical treatments

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* 6. Parental Consent

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* 7. Parents Email address

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* 8. Parents Phone Number

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* 9. Minor's Date of Birth & Age

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* 10. Parental/Guardian Consent and Acknowledgment

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* 11. Parent Signature:

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