Consent Form CONTACT & BILLING INFORMATION Name * First Name Last Name Age * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Relationship to Client * Partner, Parent, Friend Emergency Contact * LATE FEE, CANCELLATION, & NO-SHOW POLICY In order to schedule with us, we must have a valid credit card on file. This card will be securely stored in your account and will only be charged in the event of a late-fee, cancellation, or no-show. Thank you!
