HOCATT Consent Form
Name
*
Date of Birth
*
-
Month
-
Day
Year
Gender
Please Select
Male
Female
Email
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Weight (in pounds):
*
Prior to your session, you will consume at least half your body weight (pounds) of water (in ounces) the day of your appointment? Example: If you weigh 150 pounds, drink at least 75 ounces of water.
Yes
No
Please list ALL current daily medications, herbs and/or supplements and their doses:
*
Do you have any other medical conditions that the staff / practitioner / technician should be aware of?
*
CONTRAINDICATIONS:
*
Fever.
Excessive (500+ mg) caffeine intake.
Under Age18.
Taking diuretics, or medications that impair sweating or increase health risks from heat exposure.
Heat Sensitivity.
Low blood sugar levels (empty stomach).
Day of your appointment: Have you eaten a heavy meal (past 30 mins)?
Little or no sleep the night before.
Uncontrolled and/or malignant high blood pressure.
Hypotension.
Taking blood pressure medication.
Blood clots, DVT's or strokes.
Elevated blood alcohol or drug levels.
Pregnancy / breastfeeding.
Bleeding tendencies e.g. hemophiliacs.
Active bleeding (injury)/ bleeding tendency i.e. menstruation, hemophilia.
Heart conditions e.g. heart failure, blockages, recent heart attack, arrythmias, etc.
Recent surgery (past 72 hours).
Broken, injured, swollen, inflamed or infected skin on the hands or feet.
Cancerous/ malignant tissue.
Epilepsy and/or seizures.
Electrical implants e.g. pacemaker, cochlear implant, intrathecal pump, insulin pump, etc.
Implanted metals e.g. pins, plates, screws, joint replacements, mechanical heart valves, metal stents, staples in blood vessels, etc.
Breast implants.
Grave's Disease.
Organ transplant patient, i.e. taking immune suppression medication.
Thyrotoxicosis/ hyperthyroidism.
G6PD deficiency (Favism)/ hemolytic anemia.
Cutaneous porphyria.
Vitiligo.
Please check the box to acknowledge you have read and understand:
*
Signature
Powered by
Jotform Sign
Clear
Continue
Continue
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform