Oxygen Hydroxy - Health Intake Form

Oxygen Hydroxy - Health Intake Form

Please complete the following information prior to undergoing your Oxygen Hydroxy session
Full Name*

First NameLast Name
Date of Birth

DayMonthYear
Date
Phone Number*

Area CodePhone Number
E-mail
example@example.com
Contact Person*

First NameLast Name
Related*
Phone Number*

At Renessence, your well-being is our utmost priority. We strive to ensure not just high-quality service but also the safest environment for your treatments.

To uphold safety standards, we must be aware of any medical conditions or medications you're using. This information is held strictly confidential.

The following information is provided to assist you in determining if you are eligible to undergo an Oxygen Hydroxy Treatment.
CONTRAINDICATIONS AND CONSENT FORM

ABSOLUTE CONTRAINDICATIONS:

- Pneumothorax, Pulmonary Hyper Expansion

- Ear Drum Perforation

- Pregnancy

NOTE: One of the factors to take into consideration before treating a guest in mHBOT is the interaction of prescription medicines with a mild hyperbaric experience. Most of them are indicated, some require monitoring others are contraindicated, and some are relatively contraindicated, as the case may be. Pressure in the chamber (1.3 ATA) has no dangerous effects to be avoided or minimized, except for the contraindications shown in this manual.
Do you present any of the above contraindications? If YES, please indicate which one:*

RELATIVE CONTRAINDICATIONS

Any of these occurrences may disqualify the Oxygen Hydroxy candidate subject to prior evaluation and urgency:

1. Asthma.
2. Anaemia.
3. Emphysema.
4. Fever (>38.5°C). Colds, flu or COVID symptoms.
5. Jaundice.
6. Past or present middle ear problems or surgery.
7. Convulsions.
8. Undergoing chemotherapy treatment for cancer.
9. Otic barotraumas (ear pain or damage to the ears).
10. Pregnancy.
11. Respiratory diseases, blocked ear canal, blocked sinuses.
12. Viral infections.
13. Recent alcohol consumption.
14. Pneumothorax, pulmonary hyperextension.
15. Eardrum perforation.
Do you present any of the above contraindications? If YES, please indicate which one:*

GENERAL TERMS AND CONDITIONS

By proceeding, I confirm that you have read and approved the Terms & Conditions and House Rules by Renessence.
I Agree to the Terms and Conditions and House Rules*

Yes