Dr Marina Kiktenko-Stone - Tinnitus Application Form

Personal Details

Terms and Payment

Important Information

By signing this application I confirm that I have understood that the procedure that I am about to undertake does not guarantee that it will cure my tinnitus and that I am willing to proceed without confirmation from my own GP or Consultant. I have had the contra indications explained to me and agree that I am not suffering from epilepsy or any psychotic disorder. I also understand that I should not undergo any procedure, or if I am unsure of anything that may apply to a specific condition, without consulting my GP or Consultant first. It is my responsibility and not that of Dr Marina to consult my GP or Consultant. I hereby indemnify Dr Marina against any adverse reaction sustained as a result of the procedure.

* I accept the Terms and Conditions

Further Details