HOCATT Consent Form
Date of Birth
Street Address Line 2
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.
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?
Excessive (500+ mg) caffeine intake.
Taking diuretics, or medications that impair sweating or increase health risks from heat exposure.
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.
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.
Organ transplant patient, i.e. taking immune suppression medication.
G6PD deficiency (Favism)/ hemolytic anemia.
Please check the box to acknowledge you have read and understand:
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