Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I understand that before & after pictures will be taken as asset protection & for marketing purposes. No addresses will be disclosed when marketing. *

Yes

I understand that invoices are to be paid when Contractor/Employer agreed upon. Failure to pay the invoice will result in invoices being due the day of as well as a $50 late fee & all future appointments will be suspended until invoice & late fee are settled in full. *

Yes

I understand that my provider needs 48 hours notice for cancellations/rescheduling- failure to comply will result in 50% of what the service was supposed to cost. *

Yes

Do you want a copy of this waiver? *

Yes

No

Date *

MM

DD

YYYY