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Welcome! We are so grateful to have you as our guest and enrich your personal wellness. Please fill out this contact form to the greatest extent possible and return to a team member upon completion.

Cancellation Policy:

We require 24hrs notice to change, rescedule or cancel an appointment. Out of respect and support for our Service Providers we will automatically charge the card on file.  Please give us a call if you have any questions.

I Agree

 

First Guest Name

First Name*

Last Name*

Phone*
First Guest Date of Birth*
First Guest Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
First Guest Signature*
Second Guest Name

First Name*

Last Name*

Phone*
Second Guest Date of Birth*
Second Guest Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
Third Guest Name

First Name*

Last Name*

Phone*
Third Guest Date of Birth*
Third Guest Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
Fourth Guest Name

First Name*

Last Name*

Phone*
Fourth Guest Date of Birth*
Fourth Guest Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
Fifth Guest Name

First Name*

Last Name*

Phone*
Fifth Guest Date of Birth*
Fifth Guest Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
Sixth Guest Name

First Name*

Last Name*

Phone*
Sixth Guest Date of Birth*
Sixth Guest Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
Seventh Guest Name

First Name*

Last Name*

Phone*
Seventh Guest Date of Birth*
Seventh Guest Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
Eighth Guest Name

First Name*

Last Name*

Phone*
Eighth Guest Date of Birth*
Eighth Guest Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
Ninth Guest Name

First Name*

Last Name*

Phone*
Ninth Guest Date of Birth*
Ninth Guest Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
Tenth Guest Name

First Name*

Last Name*

Phone*
Tenth Guest Date of Birth*
Tenth Guest Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
How did you learn about Gervais?*
Which location do you usually visit?*

What pronouns do you use? (OPTIONAL)
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above- described permission has not been granted.*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 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.


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