For my records, I need to confirm that you have read, understood and answered all of the previous questions. If there is anything you do not understand, or wish to ask about, please ask me now (before signing this statement).
Otherwise, please read the following statement, and sign below to show that you agree.
To the best of my knowledge, the information I have given in this form is true, and I have not withheld any information concerning my health.
I will keep Ema Melanaphy updated on my health, should there be any changes to the answers already given.
I understand there is a possibility I may experience some minor reactions as my body adjusts to the treatment.
I understand that the therapist does not diagnose illness, disease or any other physical or mental condition. I understand that this treatment is not a substitute for medical examination, diagnosis or treatment. While I recognise that all due care will be taken by the therapist, I am aware that my participation in the treatment is voluntary.
