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CONSENT FORM FOR LASER TREATMENT

BETWEEN:

IEVA OLIVEIRA
PERMANENT BEAUTY BY IEVA
2072 SOLAR PLACE, L1L 0A4
OSHAWA, ONTARIO

AND

Participant

Clients will be informed in detail about the removal process using laser by technician. Technician is obligated to perform treatment in strict compliance with all hygiene and health protection measures. Laser treatment on a model is free of charge. Taking part in treatment is voluntary, and there will be no penalty if Client doesn’t want to participate. Client may discontinue participation at any time without penalty.

HEALTH CONDITION

Use of a laser for removal treatment is a very safe and predictable form of treatment. Laser energy is not ionizing radiation (i.e. x-rays). Lasers are electromagnetic radiation sources with coherent, mono-frequen- cy spectra in the range of infrared (p m) to UV (nm}.

Safety glasses are worn to protect the eyes from any unforeseen effects. These glasses are specific to the type of laser being used.
This information is confidential and saved only in written form, available only to the Technician and it shall be handled in such manner. It will not be shared with third party. By signing this document, you accept to receive information from the Technician by e-mail.

Before signing this consent form, technician of the procedure inquired the Client of possible problems or diseases that are inadvisable for the performance of the procedure. The Client does not have active process on the skin (inflammatory reactions, infections, neoplastic), fresh new tattoo (below 2-3 month), skin neoplasm, resent hemiotherapeutic aplications, liver disfunction, antibiothic therapy {local- ly or ingested}, haemophilia, diabetes mellitus, hepatitis, HIV and/or any other infectious diseases, recently tanned skin (within the last month), history of keloid scarring, diabetes, unles under control, cancer or heart disease, is not pregnant, and understands that the procedure will not be performed if any aforesaid problem exists. The Client does not consume any medication for blood thinning (anticoag- ulants}, fluoroquinolone antibiotics (ciprofloxacin, levofloxacin), tetracyclines, medicaments Vitamin A derivatives (Retinol, Isotretinoin etc.), chemical that strongly interact with liver funkction (Paracetamol in high dose (above 4grams}, NSAIL, antibiotics, Hjertemagnylis, orpharin, regularly administered anti-in- flammatory medicines), patience on antikoagulantnoj terapiji. Gold salt ingestion for rheumatoid arthri- tis can result in blue-grey skin discoloration in laser treatment areas.

WARRANTY

Technician accepts liability in compliance with the legal measures and regulations in the case of negligence or carelessness or intentionally or negligently caused injuries or threat to life, body and health. Contracting parties are liable for violations of the obligations specified under the Agreement.

EXPLANATION

The client is informed in detail by Technician about risks of laser treatment. The following risks are specifically explained to the client: During the treatment, despite expertise and all the precautionary measures, the injury is possible. Despite the application of the most advanced and the top quality products, allergic reaction is possible but rare. The client is informed about this and he/she assumes liability. During and after the treatment temporary swelling, redness and/or itching may occur. Experience tells us that these symptoms are temporary. The client is informed of hygiene measures that must be taken to avoid inflammatory reaction.

If the trated feels tender or warm- apply cold compresses of ice, or a pack of peas from freezer wrapped in a clean cloth. Do not apply ice directly onto the skin as this can burn, any creams/lotions to the area other than that recommended by your technician.
Up to 48 hours after treatment avoid to the treated area: restrictive closing or excessive friction of the trated area; contract sports or any other activity that puts you at risk of causing trauma; applying creams, moisturisers, make up, perfume or body lotions, hot baths, saunas and Jacuzzis; going swimming; shaving; rub or scratch; do not lie in the sun, use a sun-bed. In the next seven days is recommended to use sun protect.

Technician cannot be liable in case of improper post-treatment care.

COMPETENCE

If there are any questions about the treatment or if there is a treatment-related injury or adverse event, the Client can contact (Name, phone number and e-mail of contact person)

I certify that I have read and fully understand the above authorization and informed consent and the information referred to above and that all my questions have been answered to my satisfaction.

No guarantee of success has been given to me that the proposed treatment will be successful to my complete satisfaction. I understand and appreciate that the intention of the Technician is to eliminate a potential pathologic condition.

By signing below I acknowledge that you have read this document, understand the information presented and have had all of your questions answered satisfactorily.

Today's Date: April 18, 2024

First Client Name

First Name*

Last Name*
First Client Date of Birth*
First Client Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
First Client Signature*
Second Client Name

First Name*

Last Name*
Second Client Date of Birth*
Second Client Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
Third Client Name

First Name*

Last Name*
Third Client Date of Birth*
Third Client Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
Fourth Client Name

First Name*

Last Name*
Fourth Client Date of Birth*
Fourth Client Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
Fifth Client Name

First Name*

Last Name*
Fifth Client Date of Birth*
Fifth Client Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
Sixth Client Name

First Name*

Last Name*
Sixth Client Date of Birth*
Sixth Client Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
Seventh Client Name

First Name*

Last Name*
Seventh Client Date of Birth*
Seventh Client Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
Eighth Client Name

First Name*

Last Name*
Eighth Client Date of Birth*
Eighth Client Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
Ninth Client Name

First Name*

Last Name*
Ninth Client Date of Birth*
Ninth Client Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
Tenth Client Name

First Name*

Last Name*
Tenth Client Date of Birth*
Tenth Client Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

HEALTH CONDITION QUESTIONNAIRE

In order to perform the laser treatment in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of these medications? 

Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
Hemophilia*
No
Yes
Skin diseases*
No
Yes
HIV+*
No
Yes
Skin diseases*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants}?*
No
Yes
Are you pregnant?*
No
Yes
Have you undergo laser treatment ever?*
No
Yes

If your answer is yes, please write when it was.
Are you taking any medications on daily basis?*
No
Yes
Did you in the last 24 hours consume medications?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions?*
No
Yes

CONTRACTUAL OBLIGATIONS

I consent to photography, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.*
No
Yes

COMPETENCE 

I confirm that I have read and understood the aforementioned information.*
No
Yes
I received a clear and understandable response to all my questions.*
No
Yes
The treatment procedure and post-treatment care was explained to me in detail and I agree with it.*
No
Yes
I do not have any further questions and complaints.*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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