Requested Info Consent Form
Patient’s Name:
File No.:
DOB:
Mobile Number:
Doctor Name:
Visit Date:
I hereby consent to the application of MBST treatments and the subsequent compulsory review sessions.
I hereby agree to drink approximately 2 liters of water per day, from the date of signature throughout the treatment period and during the full extent of the aftercare process.
I hereby agree to comply with the indications stated above and have paid a non-refundable deposit.
Like any medical procedure or therapy, there is no guarantee that MBST will work 100% for everyone.
The worldwide success rates are 80-90%.
The treatment of all sessions must be completed within the specified time frame and will expire 6 months from date of first session.
Patient Name & Signature :
Doctor/Therapist Name & Signature :
Witness Name & Signature :
Parent or Gaurdian Name (if patient is minor) :
Date :