Laserfiche WebLink
Cl...IENT NAME: <br /> CAST NAME FIRST NAME <br /> CONSENTAND 1REl._E.4SE ACIR.EEMENT FOZPERMANENT- <br /> COSMETIC PR.00EDKP e(S) <br /> PLZAS E� PR.I Nl-- <br /> DATE: <br /> NAME: <br /> ADDRESS: <br /> CITY, STATE, AND ZIP: <br /> PttONE NWM$C-R,(S): ttOME: CEL. -: <br /> E-MAI L ADDRESS: <br /> I agree to foLLow the aftercare LwstrucewKs a f der the pernmawevLt cosvu et c procedure. <br /> LwLtLals <br /> I agree that aKU touch up worl2 weeded due to mU oww wegl.Lgewce 11Kl Lads, <br /> or correctLve worl2 due to vv.0 chaKOLvi.g vwo vu.LKA about what I wawt, wUL be at MU <br /> expemsse Lvatio Ls. <br /> DO YOIA KAVE A MEDICAL CONDITION I SHtOR D BE AWAZe OF? <br /> YES NO <br /> if des,please"describe covL.AtLov%, <br /> who do I "tifu <br /> w. case Of aw ewe ergewcO? <br /> Nawtie Phowe wumbers home/worle <br /> I have read the above LwforntatLovti a" herebU 3Lve rw0 cowsewt for tWs Pervt&aKtvt <br /> Cos metiz procedure. S I c,NAT1.tRE <br />