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Personal Information

Please complete the following fields with your personal information. Fields marked with an asterisk (*) are required.

Stop Smoking Therapy

By completing this form you agree to have read, understood and agreed that:

  • Is it important to know that if you have been diagnose with cancer, following cancer treatments, have a spine stimulator, pregnant of more than 12 weeks you will not be able to do this laser treatment;
  • If products must be returned it must be within 10 days of the purchase and seal must not be broken;
  • Although there is a high success rate (85%-90%), we do not guarantee that you will quit smoking;
  • Although a lot of insurance companies do cover this treatment, we do not guarantee that yours will;
  • The answers on this form are accurate and complete. You release Clinic Laser Therapy from any responsibility for any incidents arising from inaccurate, incomplete or incorrect answers.


Notice fees for absence

Madam, Sir, In order to help us provide you with a good quality service, it is necessary that you attend all your appointments. Please note that if you are unable to attend your appointment on the day and time agreed, you must notify us at least 24 hours in advance. Otherwise, you will lose your appointments. Late arrivals or repeated absences could obligate us to close your file. I was informed of this management policy.