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No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.
All deposits and booking fees are non-refundable unless agreed to with the practitioner.

Do you understand the information you have been provided?
Do you feel sufficient information has been provided to you, to enable you to consent?
Has your consent been freely given?
Do you have any medical conditions?
Are you pregnant or breastfeeding?
Do you have a neuromuscular disease (e.g. MS, ALS, motor neuropathy myasthenia gravis, or Lambert-Eaton syndrome)?
Do you have an autoimmune disease?
Do you have any skin conditions?
Do you have any known allergies or have ever had anaphylaxis?
Do you have any active infection at the intended site of procedure?
Are you taking antibiotics or other prescription medications?
Is there any other Medical and/or Social History that we should know? If so, please provide full detail here.
Have you had this or a similar treatment before? If so, did you experience any problems? Please provide full details here.
Do you have any concerns? If so, please provide full details here.
I will retain this information throughout the course of my treatment and refer to it as required.

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