Participant Agreement, Release and Assumption of Risk (the “Agreement”)

Date Seen & Agreed *

First Name *

Last Name *

Your Date of birth *

Email *

Phone *

Zip Code *

Participant First Name (1)

Participant Last Name (1)

Participant Date of Birth (1)

Participant First Name (2)

Participant Last Name (2)

Participant Date of Birth (2)

Participant First Name (3)

Participant Last Name (3)

Participant Date of Birth (3)

Participant First Name (4)

Participant Last Name (4)

Participant Date of Birth (4)

Signature of Adult Participant / Parent or Guardian *

Clear

Promotional Consent

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply STOP to opt-out.

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.