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Waiver Form
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*
" indicates required fields
Name
*
First
Last
Date Of Birth
*
MM slash DD slash YYYY
Email
*
Phone
*
List Any Health Concerns (if no health concerns skip this section )
Diabetes Status
Do you have diabetes?
*
Yes
No
What do you take?
*
Insulin
Oral Agents
Diet Controlled
How often do you test blood sugar?
*
Please enter a number from
0
to
100
.
Pulmonary Lung Diagnosis
Have you ever been diagnosed with any lung/pulmonary fibrosis?
*
Yes
No
What is the condition?
*
Pregnancy status
Are you pregnant or think you could be?
*
Yes
No
Ear History
Have you ever had ear problems?
Yes
No
Do you have problems with your ears when you fly?
Yes
No
Do you know how to equalize the pressure in your ears?
Yes
No
Medical Devices
Do you have any medically implanted devices? If so, what are they?
I am voluntarily participating in hyperbaric oxygen therapy at my own risk. I am aware of the risks associated with participating in this activity.
I hereby release and forever discharge HBOT USA, their affiliates, managers, members agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned activity.
Consent
*
I hereby acknowledge that I have carefully read this waiver and release and fully understand that it is a release of liability.
Signature
*
First
Are you interested in owning a hyperbaric chamber?
Yes
No
Would you like someone from our team to contact you and answer any questions regarding chamber pricing and/or our training courses and business coaching programs?
Yes
No
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