• Body Treatments and Skin Care Consent Waiver

    The Gestalt House LLC - SERVICE INFORMATION AND MEDICAL HISTORY - READ CAREFULLY - CONSENT TO TREATMENT
  • Format: (000) 000-0000.
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  • Fees

    All costs are payable in full prior to or at the time of treatment and are non-refundable. Payments must be completed for entire package price (1, 3, or 6 sessions) on first visit to receive package discount. Packages once purchased and treatment initiated are non-refundable. 

  • Medical Background

  • Format: (000) 000-0000.
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  • Consent to Treatment

    The Gestalt House LLC - READ CAREFULLY

  • Disclosure

    Beauty treatments, the practice of skin care, and the practice of massage, including, but not limited to, waxing, facial toning/massage, body scrubs, body massage techniques and treatments, reflexology, dermaplaning, LED light therapy, brow lamination, brow tinting, lash lifts, lash tinting, lash extensions, and various other beauty procedures is not an exact science and no specific guaranties can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference. Subsequent visits are subject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person and The Gestalt House LLC (Inspired Offerings Spa Powered by The Gestalt House LLC) does not guarantee any specific result.

     
    All charges/payments are processed through The Gestalt House LLC.

  • Aftercare

    After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow after care instructions may compromise the final results of the treatment. 

  • Before, During, and After Pictures and/or Video

    Client understands and agrees to: Before, during and after pictures and/or videos will be taken to document the treatment. These pictures or videos become The Gestalt House LLC’s sole property and may only be used for its legitimate business purposes (email, text, or social media). Client names will not be used unless client has provided written permission (email, text, or social media comment) to do so.

  • Release

    I recognize that there are certain inherent risks associated with the esthetic and massage treatments, and I assume full responsibility for personal injury to myself. In exchange for such treatments, I hereby fully release and forever discharge The Gestalt House, LLC (including its officers, members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself, The Gestalt House, LLC or other third parties, or in any way arising out of the above described treatment I have requested The Gestalt House, LLC perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment, or services provided by The Gestalt House, LLC including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under Missouri law. I agree to indemnify, hold harmless and defend The Gestalt House, LLC (including its officers, members, owners, employees and agents) against all third-party claims, causes of action, damages, judgments, costs or expenses, including attorneys’ fees and other litigation costs, which may in any way arise from the above-described treatment I have requested The Gestalt House, LLC perform.

     
    I understand this completed and signed consent for cover and apply to all present and future treatments herein mentioned.

  • Arbitration

    It is understood that any dispute arising as to malpractice of treatment shall be decided by a neutral arbitrator. Any arbitration proceeding will be governed by Missouri’s arbitration statute, the fees for the arbitrator will be split pro-rata among the parties and each party will be responsible for their own attorneys’ fees and costs. Any action to collect fees from the client/patient for the treatments performed may be brought in any court located in Greene County, Missouri and the prevailing party in such collection action shall be entitled to recover its reasonable attorneys’ fees and costs. Filing of any action in any court to collect any fee from the client/patient shall not waive the right to compel arbitration of any malpractice claim.

     
    By signing this agreement, I confirm that I am over the age of 18. I certify that I have read the above paragraphs; fully understand this consent and treatment form and herby consent to the indicated treatment(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the esthetic and massage treatments which is to be performed at my request according to this agreement and I hereby agree to arbitration of any malpractice claim. I further understand that by signing this agreement, I surrender certain legal rights. 

  • Electronic Signature and Consent

    I agree and understand that by signing this Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature, and I consent to be legally bound to this agreement.

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