I declare that:

I have read the entire form, and all the details I have reported on this form in all its parts are complete and correct.

I declare that I have received a detailed explanation of the treatment method performed by a qualified therapist.

It was explained to me before I signed this form that the treatment does not guarantee an improvement in my health or a partial/full recovery.

It was explicitly made clear to me that there may be possible side effects to the treatment, and I will have no claim, demand, or lawsuit of any kind against Linor Lev.*