parental consent form

TOOTH JEWELLERY GUARDIAN CONSENT FORM

The information being collected on this form will only be used for the purpose of parental consent for any client who is under the age of 18 and wishing to have the treatment, specified below

Crystal Canine requests that you complete the details below and return to us prior to treatment, this form will then be stored along with the young person's record card. If the client is between the age of 16 - 18 they will also be required to have a parent or guardian present throughout the treatment.

Please fill out your details below:
Parents name*

First NameLast Name
Minors name*

First NameLast Name
Relationship to young person*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*
I am happy to give my consent for the minor stated above to have the specified treatment/s. I have checked the record card details and can confirm they are correct. Both myself and the young person fully understand what the treatment involves and have read and understood any pretreatment and aftercare advice.*

Confirm
Signed by minor*

Clear
Signed by parent/guardian*

Clear
Please upload picture of both ID's*

Cancelof
Proof of guardianship such as a birth certificate

Cancelof
Date*

DayMonthYear
Date
Should be Empty: