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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*
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. *
Yes
No
First Guest Signature*
Second Guest Name
First Name*
Last Name*
Phone*
Guest Date of Birth*
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. *
Yes
No
Third Guest Name
First Name*
Last Name*
Phone*
Guest Date of Birth*
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. *
Yes
No
Fourth Guest Name
First Name*
Last Name*
Phone*
Guest Date of Birth*
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. *
Yes
No
Fifth Guest Name
First Name*
Last Name*
Phone*
Guest Date of Birth*
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. *
Yes
No
Sixth Guest Name
First Name*
Last Name*
Phone*
Guest Date of Birth*
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. *
Yes
No
Seventh Guest Name
First Name*
Last Name*
Phone*
Guest Date of Birth*
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. *
Yes
No
Eighth Guest Name
First Name*
Last Name*
Phone*
Guest Date of Birth*
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. *
Yes
No
Ninth Guest Name
First Name*
Last Name*
Phone*
Guest Date of Birth*
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. *
Yes
No
Tenth Guest Name
First Name*
Last Name*
Phone*
Guest Date of Birth*
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. *
Yes
No
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*
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. *
Yes
No
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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