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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.