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I, the undersigned, understand all questions and verify that all information is complete and accurate to the best of my knowledge. I also understand that the hypnotic methods used by Anthony M. Davis of Healing Hypnosis are not a substitute for medical or psychiatric treatment.

I understand that during hypnosis, it may be necessary to touch my hand, arm, shoulder or forehead. I give permission to Anthony M. Davis of Healing Hypnosis and consent to do so in order to help me establish a beneficial state of hypnosis.

I understand these methods to be a conditioning process, whereby an individual is taught to use their own abilities for their benefit and well being. With this understanding, I hereby grant the Anthony M. Davis of Healing Hypnosis permission to hypnotize me or the minor child whose name appears at the top of this form. I (we) further grant permission for the sessions to be recorded as needed.

I know my progress is dependent upon my efforts and that there are no guarantees as to the result or progress to be made. I understand that the success of the hypnosis sessions will be in direct proportion to my commitment to the end result.

By Entering my name below, I am confirming that all information is true to the best of my knowledge, and I agree to all the terms listed above:

ALL INFORMATION ON THIS PAGE IS STRICTLY CONFIDENTIAL

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