Minor Consent Form

Minor Consent Form

Parent and/or guardian consent to treat his or her minor child with esthetic services for a given amount of time.
Parent's Name*

First NameLast Name
Minor Child's Name*

First NameLast Name
Minor Child's Birth Date*

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent E-mail
Parent's Phone Number*

Area CodePhone Number
Please write any additional comments or questions you have as the parent of the minor receiving esthetic service.
Service being performed
Today's Date*

MonthDayYear
Date
Terms & Conditions I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the clinic will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

By checking I agree to terms
Parent Signature*
Should be Empty: