CONSENT FORM

After my preliminary examination, I have given consideration to all of the information received, including the possibility that rare and undesirable side effects may occur, such as : redness in the area of the injection, swelling, local pain, increased temperature, eruption on the skin, diarrhea, anaphylactic reaction or late sensitization syndrome.

Having read the above, I confirm that I wish to undergo the cellvital therapy and herewith give my authorization for CLP to proceed. 

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同意书

经过初步检查，我已认真考虑所提出的所有信息，包括出现可能性极小的副作用的发生，例如：注射区出现红色、肿胀、局部疼痛、体温升高、皮肤上出现丘疹、腹泻或过敏性反映。

以上问题我已经认真阅读，并确定进行活细胞治疗。同时，授权瑞士CLP健康医疗中心为我治疗。

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