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Stop Smoking Clinic of
America
AGREEMENT:
I fully understand that I have been accepted for therapy by the Stop Smoking
Clinic ONLY because they feel they can help me quit smoking and, therefore, I
certify that these conditions have been explained to me and I agree to the same;
I am absolutely serious about wanting to quit smoking. I will do my best to
follow instructions exactly and fully.
RELEASE:
I hereby certify that the therapy sessions of the Stop Smoking Clinic, which are
designed to aid me in breaking the smoking habit, have been explained as
follows;
During said therapy sessions, a mild stimulus will be applied to my forearm or
wrist. It is an impulse that is uncomfortable, but is safe and harmless. Also,
during this therapy I will be smoking under the MOST ADVERSE CONDITIONS
POSSIBLE, which might make me nauseated for a short time.
I hereby release the Stop Smoking Clinic, my therapist, and any assistants from
any and all responsibility if said therapy should have any adverse effects upon
me in any way.
GUARANTEE:
In the event that I am still smoking at the end of the fifth scheduled session
and can demonstrate that fact by smoking and inhaling an entire cigarette in the
presence of my instructor, and after participating fully in one complete Stop
Smoking Therapy program (consisting of the 5—Day Quitter's Countdown and the 5
consecutive days of actual therapy) and following all instructions exactly, the
Stop Smoking Clinic agrees to allow me to attend two additional COMPLETE
programs FREE OF CHARGE.
In the event that I have still not quit smoking at the end of the THIRD COMPLETE
program, the Stop Smoking Clinic guarantees to refund my total cost.
ONE YEAR FREE FOLLOW—UP:
This follow—up is a maintenance program. The Stop Smoking Clinic will work
with me to assure my continuance as a non—smoker. However, I must call BEFORE
I start smoking again. If I smoke before I call, this follow—up and any
further obligation of the Stop Smoking Clinic is cancelled.
If at anytime during the next year, I think that I am going to start smoking
again, I will call the Stop Smoking Clinic for an appointment to go to their
office, the same day, and will receive their reinforcement program. This
maintenance program will continue on a daily basis until we mutually feel the
trouble has passed.
ASSISTANCE AGREEMENT:
I agree to write a personally signed testimony of my liberation from smoking. I
also agree to tell my friends how easily they can be liberated from the nasty,
health—destroying habit of smoking, yet I will NOT divulge exactly what the
therapy consist of.
I agree to pay a total cost of $________ before starting therapy
on__________________ .
Signature ___________________________ Date__________ Witness_________________________
Date________________
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