By supplying my Initials and declaring below I have read and reviewed all the above responses and confirm they are correct and true. I consent to having the treatment performed and understand he risks and considerations involved. I understand that the provider of the procedure takes no responsibility for any possible complications and consequences that may result from the procedure, particularly if I have provided incorrect information, if I fail to accurately disclose my medical history or if I fail to follow pre-treatment and/or aftercare procedures.
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