Appointment Consent

I, First Name* Last Name*, give permission for First Name*  Last Name*, who is myParent/Partner/Spouse/Friend*, to:

I, First Name* Last Name*, understand and agree that I can withdraw my consent at any time. The information I've given is complete and accurate. By signing this form on Date*, I confirm that I have fully informed myself of the contents of this Adult Client Permission Form by reading it before I signed it.   

First Name*Last Name*