day of treatment

First Name

Last Name

Birthday

Date of Appointment

Today's Procedure(s):

CLIENT INITIALS_____________ NEW PROCEDURE FEE(s) **check-up & touch-up fees are NOT included in this fee. **

CLIENT INITIALS_____________ CHECK-UP FEE : ** This fee is only in the event that additional work is needed and covers the consumables. ** Check-Up's must be scheduled within 6-8 weeks of your last visit. Anything past 6-8 weeks will be considered a touch-up and will have touch-up fees associated with it. · All NEW PROCEDURES require a check-up.

CLIENT INITIALS_____________ CHECK-UP must be completed by:

CLIENT INITIALS_____________ TOUCH-UP / MAINTENANCE FEE : ** After 8 weeks and up to 24 Months of your Original Procedure.

CLIENT INITIALS_____________ TOUCH-UP / MAINTENANCE must be completed by:

CLIENT INITIALS_____________ EXTENDED FEE : ** It has been over 24 months, but not over 4 years.

CLIENT INITIALS_____________ EXTENDED must be completed by:

Any procedures after 48 months will be considered a NEW procedure. Client Signature & Date

day of treatment

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