Ultrasound Cavitation and RF Treatment Consent Waiver

Disclosure

This treatment is a process, and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges, depending on the amount of work needed. Actual results vary from person to person, and The Gestalt House LLC does not guarantee any specific result. The Ultrasound Cavitation treatment carries with it possible health complications and consequences, which include but might not be limited to the risk of kidney failure, liver failure, pacemaker failure, congenital disability, miscarriage, thyroid damage, damage to the ovaries, lactation complications, hyper-triglyceridemic, hypercholesterolemia, pancreatitis, infection, scarring and/or allergic reaction to any products used, excessive thirst, dehydration, nausea. The Ultrasound Cavitation treatment includes, but is not limited to, the use of high-power, low-frequency ultrasound cavitation, which uses 40KHz frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating micro-bubbles that increase the pressure around the adipocyte and force it to implode, thus breaking down adipocyte’s cell membrane.

The Cavitation treatment also includes Radio Frequency for skin tightening and collagen production. Radio Frequency is also used on the face and neck without Cavitation. This Radio Frequency treatment can have possible complications, such as bruising and inflammation in and around the site being worked. These are typically rare, but we like to keep our patients informed.

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.

Release

I recognize that certain inherent risks are associated with the above-described treatment, and I assume full responsibility for personal injury to myself. In exchange for such treatment, 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 the Ultrasound Cavitation and/or the Radio Frequency 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 understand that the Ultrasound Cavitation and/or Radio Frequency procedure is permanent, that such procedure has possible adverse consequences, and that the procedure is for cosmetic purposes only. I certify that I have read the above paragraphs, fully understand this consent and procedure form, and hereby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the Ultrasound Cavitation and/or Radio Frequency procedure which is to be performed at my request according to this agreement. 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.