New Client Booking- Chamber 1

Name*
First Last
Date of Birth*
DD slash MM slash YYYY

dd/mm/yyyy
Email Address*
Phone Number*
Subscribe me to your emails*
- No
- Yes
1) Have you been diagnosed with Pneumothorax (collapsed lung)?*
- No
- Yes
UNFORTUNATELY, DUE TO HEALTH REASONS YOU ARE NOT SUITABLE FOR OXYGEN TREATMENT. Please do not continue with the questionnaire.
2) Have you ever been diagnosed with epilepsy or had an epileptic seizure?*
- No
- Yes
UNFORTUNATELY, DUE TO HEALTH REASONS YOU ARE NOT SUITABLE FOR OXYGEN TREATMENT. Please do not continue with the questionnaire.
Virtual Signature*
I hereby state that the above information is true and I agree that I am suitable for the treatment of mild Hyperbaric Oxygen Therapy (m-HOBT). I also confirm that I was explained any contraindications and contra actions of m-HBOT treatment. (if under 18 please have a parent or guardian sign) I hereby give my consent and authorization voluntarily and release OxyZone Sligo Hyperbaric Chamber Oxygen Therapy from any claims, implied or state that I have or may have in the future with m-HOBT treatment, regardless of results. I am stating that the treatment and precautions above have been explained to me in detail and that I fully understand
- Yes
- No