Client information and release form

Client Information and Release Form

Please complete the form below.
Name

First NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
I consent to the services provided. I acknowledge that if I am currently under any medical treatment that I will not discontinue without the help from my health care provider and understand there is no guarantee of results for services provided. Conde Bartlett has in no way represented herself as a physician or health care provider and has not given any medical advice, treatment, or diagnosis. I hereby release the party above from any and all claims whatsoever arising from or related to any and all services performed and I agree to indemnify the party for all claims related to the services. This includes all subsequent services not included here.

Rescheduling Appointments: Twenty four (24) hour notice is required rescheduling services. Missed appointments without notice will be charged a $35.00 fee.

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Client Information and Release Form