I hereby authorise Dr.Homyra JD to treat me. I understand that the effects may not be 100% and that multiple treatments may be necessary to achieve the best results.

I understand that there are certain risks associated with this procedure. I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and those questions have been answered to my satisfaction. I fully understand the treatments conditions and procedure.

I agree to pay for the above-mentioned services and understand there will be no refund for any performed services.

This consent form and cost covers above mentioned treatments only. Additional treatments can be added to this consent form and will be charged for as per clinic price list.

I have been made award of the risk and I accept these terms and conditions as part of my treatment. Dr.Homyra JD will not accept liability for any of the above side effects. By signing, I agree to the terms and conditions and in the event of any of the above, I or any of my representatives, will not pursue Dr.Homyra JD in any means of compensation.

The objectives and methods of the injection/treatment procedure have been clearly explained to me by Dr.Homyra JD.

I have received, read and understood the information supplied by the Dr.Homyra JD prior to the injection/treatment. Including all the pages of this document.
I have had the opportunity to ask any necessary questions.
I understand the pre and post injection recommendations and I agree to follow them.
I acknowledge that I had the time required for consideration and to make my decision.
I acknowledge that I have been clearly informed of the side effects and the rare cases of medical device vigilance.
I freely and voluntarily consent to receiving injections/treatment.