Pandora Light Information and Consent Form

Name*

First NameLast Name

Email*

example@example.com

Mobile Number*

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Emergency Contact*

First NameLast Name

Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Contact Relationship*

Overview of PandoraStar Light Therapy

PandoraStar is a deep trance meditation device designed to stimulate brainwave entrainment through flickering light patterns. These sessions may enhance relaxation, meditation, creativity, and altered states of consciousness.

Risks and Contraindications

PandoraStar light therapy involves the use of flickering lights, which can trigger seizures.

If you have any to the following you are not a candidate for a PandaroStar Light session:

Epilepsy or Seizures
Family History of Epilepsy or Seizures
Pregnant
Under the Influence of Alcohol
Under the Influence of Recreational or Psychoactive Drugs

Laser Treatment on Face in the Last 30 DaysFacial Chemical Peel in the Last 7 DaysNone of the Above

I have read the above list of contraindications for participating in a PandorStar Light session and can confirm that I do not have, suffer from, or experience any of the above. *

I have read the above list of contraindications that require physician approval for participating in a PandorStar Light session and have provided said note from my physician allowing me to participate in a session if required. *

Do you require sunglasses when out in the sun?*

Informed Consent: Please read each statement carefully.

I confirm that I have read the form carefully, understand the contraindications (risks) and have answered truthfully.

I confirm that I understand the PandoraStar® lamp is NOT a medical or psychological therapy and is not intended as a treatment or remedy for any condition.

I confirm that whilst I have never suffered from epilepsy or seizures, I understand that there is a statistical chance of 1 in 3000 that I could be sensitive to flickering light and that this in rare cases could lead to a seizure.

I confirm that the nature of the PandoraStar® lamp and the session I am about to experience has been explained to me and have been advised what to do if the lights become too intense and that I have full control to stop the session at any time.

Release

I recognize that there are certain inherent risks associated with the above-described session, 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, LLLC (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 PandoraStar Light session 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.

Arbitration

It is understood that any dispute arising as to the adverse effects of the PandoraStar Light session 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 for the sessions 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 shall not waive the right to compel arbitration of any adverse effects claim.

By signing this agreement, I confirm that I am over the age of 18, I understand that the PandorsStar Light session has possible adverse consequences, and that the session is for entertainment purposes only. I certify that I have read the above paragraphs; fully understand this information and consent form and herby consent to the indicated session. This means that I accept full responsibility for these and/or any other adverse effects which may arise or result during or following the PandoraStar Light session which is to be performed at my request according to this agreement and I hereby agree to arbitration of any adverse effects 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.

Client Signature

Date Signed

Date