Client Name *

First Name

Last Name

Under 18? *

Yes

No

Parent/Guardian Name

First Name

Last Name

Client Birthdate *

MM

DD

YYYY

Appointment Date *

Available Hours for Appointments: Monday - Friday: 9am-1pm

MM

DD

YYYY

Appointment Time *

Hour

Minute

Second

AM PM

Phone Number *

(###)

###

####

Payment Method *

Credit Card

Debit Card

Venmo

I agree to the following outlandish terms :) jk imma change this one later *

I Agree