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1. Name of Client (Required.)

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2. Email Address: (Required.)

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3. Phone Number (Required.)

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

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4. I consent to this activity/procedure. (Required.)

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5. Enter date (Required.)

Date

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

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7. Parental Consent

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8. Parents Email address

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9. Parents Phone Number

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10. Minor's Date of Birth & Age

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11. Parental/Guardian Consent and Acknowledgment

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12. Parent Signature:

T