Exhale East Returning Customer Form Date Name Date of Birth Medical changes since last visit I accept that any treatment I have taken is at my own risk. I certify that i have read and completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect, unknown because of this to which I accept full liability/responsibility Disclaimer I fully understand the above concent/permit and treatment/s to be carried out. The undertaken of the treatment/s has been fully explained to me. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request. Signature: *PLEASE CLICK SUBMIT A SECOND TIME - AFTER DOUBLE-CHECKING ALL INFO IS CORRECT*