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Personal Information

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

Weight Management

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

  • Is it important to know that if you have been diagnosed with cancer, are following cancer treatments, have a spine stimulator or 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;
  • Clinic Therapy Laser does not treat health problems. The soft laser treatment is a non-invasive treatment that might be not covered by all insurance companies. Clinique Therapie Laser is not responsible for individual results.
  • The answers on this form are accurate and complete. You release Clinic Therapy Laser from any responsibility for any incidents arising from inaccurate, incomplete or incorrect answers.

Questionnaire

Questions concerning weight loss

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Notice fees for absence

Madam, Sir, In order to help us provide you with a the best quality of service, it is necessary you attend all of 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 force us to close your file. I was informed of this management policy.