Your cart is currently empty!
COVID-19: We are committed to staying current as the situation with COVID-19 evolves. Learn More
The nature and purpose of this procedure, possible alternative methods of treatments, risk involved, possible consequences, and possibility of complications have been explained to me by Dr. Fortino and or his associates. Among the possibilities; swelling, bruising, local or general reaction, infection, discoloration, nausea/diarrhea, pain, or soreness at the injection site.
I acknowledge that no guarantee or assurance has been given by anyone as to the results which may be obtained. Each patient will respond differently, and no guarantee of effectiveness, satisfaction, or duration of effect have or can be made.
I realize that statements regarding natural supplements such as vitamins and amino acids have not been evaluated by the Food and Drug Administration (FDA) and are not intended to diagnose, treat, or prevent disease.
I understand and acknowledge that payments for the above procedure are non-refundable regardless of the results.
I agree that this constitute full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs, and that I have had sufficient opportunity for discussion and to ask questions, and all my questions have been answered to my satisfaction. I believe that I have adequate knowledge upon which to give any information consent to the proposed treatment. I consent to having injections today and for all subsequent treatments.