CONSENT: I consent to receiving the Cliovana procedure as explained to me by Tammy Nolan ARNP and his/her associates (Cliovana Providers I acknowledge that I have been informed that the Cliovana procedure is non-invasive and uses sound wave technology to create long-term increases in women's sexual responsiveness and their orgasm frequency and intensity. I understand that the Cliovana procedure is not intended to diagnose, treat, prevent, or cure any disease. I understand that the Cliovana treatment may result in an orgasm at the time the treatment is performed. I know that if I have any questions about the procedure, I will be sure to ask the Cliovana Providers about them. I know it is up to me to tell the Cliovana Providers about any health problems or allergies I have. I must also tell the Cliovana Providers about drugs or medications I am taking. Further, if do not fully understand the procedure or its risks and consequences, I have the right to question the Cliovana Providers or other professionals and it is my responsibility to do so.
NOGUARANTEES: I understand that the Cliovana Procedure is not an exact science and that no
guarantees or promises have been made to me concerning the results of the procedure by the Cliovana Providers. Some individuals are greatly improved and for others no appreciable improvement is noted.
MY SIGNATURE BELOW INDICATES MY ACKNOWLEDGEMENT THAT: (1) I HAVE READ, OR HAD READ TO ME, AND UNDERSTAND ALL OF THE INFORMATION ON THIS FORM; AND (2) HAVE BEEN GIVEN AN OPPORTUNITY TO ASK QUESTIONS AND ALL OF MY QUESTIONS ABOUT THIS FORM HAVE BEEN ANSWERED TO MY