Questionnaire

Past and present medical problems – Please mark yes/no

Your nutrition *

• I confirm that I have read and understood the questionnaire and that I have provided accurate details to the best of my knowledge.

• I understand that this treatment for neutralizing emotional barriers performed in the clinic and/or online remotely is not psychological treatment and does not replace conventional and/or medication treatment that I receive.

• I understand that 85% of patients report treatment success and I am interested in receiving treatment at the Ora Golan Center.

• Payment is for a package of 4 treatment sessions where the period for implementing all treatments is one year from the date of the first treatment. Each additional treatment plan is valid for one year only from the date of purchase. I understand that I will be charged for an appointment that is not canceled at least 24 hours in advance.

• I understand that after the start of treatments I will not be entitled to any refund even in case of a request for cancellation or waiver of part of the treatments, taking into account that some patients report treatment success after a smaller amount of treatments than what I am entitled to according to the package I purchased.

• The duration of a standard treatment session is up to 20 minutes. Sometimes, due to the therapist's professional discretion, the treatment session may be shortened or extended. At the end of the treatment, it will be possible to receive a comparative report describing your condition before and after treatment according to the patient's report only.

• *** Ora Golan Center reserves the right to make price changes