Parental Consent Form

Parental/guardian Consent Form

Clients under the age of 18 (unless emancipated) can only receive services with parental/legal guardian consent.

Parent/guardian have the option to be present in the treatment area with minor.

Name of minor.

First Name

Last Name

Child's Birthday

YYYY

Name of Parent/Guardian

First Name

Last Name

Emergency Contact Number

(###)

###

####

Date of minor's appointment.

YYYY

As the parent or legal guardian of the above listed minor, I give permission for my child to have treatment done.

I agree

I give consent for my child to be in the treatment room without me

My child will be accompanied by a legal adult that is not the parent.

Minor will be accompanied by an adult nanny, babysitter, aunt, uncle, sister, brother or cousin (must be over 18 years old).

I confirm I have read and understand all information on the applicable forms for treatment(s) requested above, and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree to supervise any home care procedures that are recommended, as per treatment.

I agree.

I have read the above information and give permission for my child to receive skin care services from Clean Beauty Quyen. I release Quyen Ly of Clean Beauty Quyen of all liability for any services rendered.

I agree

Type Name for Electronic Signature