Medispa Client Application Form

MEDISPA CLIENT APPLICATION AND SERVICE AGREEMENT

Client & Facility Information

RECITALS

WHEREAS, Client Name: seeks cosmetic, dermatologic, or aesthetic treatments to be performed by Medispa Name: ; and

WHEREAS, Medispa represents that it employs or contracts with licensed clinicians and trained staff to perform such procedures in accordance with professional standards and applicable law; and

WHEREAS, the parties desire to document Client's medical history, consent to treatment, payment arrangements, and certain contractual terms governing the provision of services.

SCOPE OF WORK

The Medispa will perform the services requested by Client as set forth below. Services will be provided only by or under the direct supervision of licensed personnel in the scope of their training.

MEDICAL HISTORY & CONSENT

To the best of my knowledge, I have provided a complete and accurate medical history. I understand the nature of the proposed treatments, the potential benefits, risks, and alternatives, and I consent to the performance of the treatments described in the Scope of Work.

PAYMENT TERMS

Client agrees to pay Medispa for services described in the Scope of Work in accordance with the following terms.

Late payments shall incur a late fee of: on any unpaid balance. Client authorizes reasonable collection costs, including attorney fees, for delinquent accounts.

TERM AND TERMINATION

This Agreement commences on Start Date: and continues until End Date: unless earlier terminated in accordance with this section.

Either party may terminate with prior written notice of Notice Period (days): days. Medispa may suspend services immediately for nonpayment or breach of pre-procedure instructions. Termination does not relieve Client of the obligation to pay for services already rendered or non-refundable deposits.

CONFIDENTIALITY

Both parties agree that confidential information exchanged in connection with this Agreement, including medical records, treatment plans, and non-public business information, shall be kept confidential and used only to perform obligations under this Agreement. Medispa may disclose client information as required by law, to healthcare providers for continuity of care, or with Client's written authorization. Any disclosure outside these exceptions requires prior written consent.

ASSUMPTION OF RISK, RELEASE & CONSENT

Client acknowledges that aesthetic procedures carry inherent risks, including but not limited to infection, scarring, allergic reaction, asymmetry, pigmentary changes, and unsatisfactory results. Client voluntarily assumes these risks and releases Medispa, its owners, employees, and contractors from liability for ordinary negligence to the extent permitted by law. Client consents to procedural photography and the use of anonymized images for clinical documentation and education unless Client indicates otherwise below.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State specified below without regard to conflict of law principles.

ENTIRE AGREEMENT

This Agreement, together with any documented treatment plan and disclosures signed by Client, constitutes the entire agreement between the parties concerning the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether written or oral. Any amendment must be in writing and signed by both parties.

EMERGENCY CONTACT

CERTIFICATIONS & ACKNOWLEDGMENTS

By signing below, Client certifies that the information provided herein is true and complete to the best of Client's knowledge; that Client has read and understands the risks, benefits, and alternatives to the proposed treatments; and that Client consents to the treatments described in the Scope of Work. Client further authorizes Medispa to perform those procedures consistent with professional judgment.

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