I give permission for Specialty Foot Care by Brooke Gordon, RN or her qualified designee to provide nail care for the above listed patient.

I understand that services will be provided every month/every other month.

The cost of each service is $40 per visit. Please choose your billing option:
1 - Upfront in advance ($40 x 3 = $120)2 - Secure credit card on file

Billing preference/please fill out all information:
1 - I would prefer to receive emails2 - I would prefer to receive paper mail