Parental Consent for Treatment
Please complete this form to provide consent for your child to receive treatment at Beauty at the Lodge.
Child's Full Name
*
First Name
Last Name
Childs Date of Birth
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
County
Post Code
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
What treatment is the child named above going to be receiving?
What Date will they be receiving Treatment?
-
Month
-
Day
Year
Date
Have you completed the beauty consultation on behalf of the child?
Please Select
Yes
No
If you have answered No please complete this before proceeding and submitting this form. Your child will be unable to receive treatment without both forms being completed and answering Yes to this question.
I hereby give my consent for my child to receive the treatment named and I have been fully informed of the procedure and any contra indications. Please Enter your Relationship to the child below:
Parent/Guardian Signature
*
Date signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: