Waiver / Preorder Information

I, the client, understand and acknowledge that I am choosing to self-inject.

I understand that I, the client, am only to make use of insulin-type syringes provided and will follow the hygiene guidelines provided.

I acknowledge that I, the client, should ensure the injection area has been wiped with an alcohol swab before self-injecting.

I hereby acknowledge that neither the product manufacturer nor any other party shall be held responsible for complications or infection involved by, or resulting from, the hygiene conditions under which the self-injection is done.

By proceeding with the lipolysis injection, I, the client, attest and certify that I have read and understood the information of this form and the information sent prior.

I agree that I, the client, have had sufficient opportunity for discussion and to ask questions and agree that I will be going forward with the treatment of my own free will and am aware of the procedure, what to expect, and any risks.

To Order

Please send the following:

• Name and Surname
• Email
• Cell Number
• Delivery Address
• Date of Birth
• What you wish to order (for invoicing)