PRICING AND BOOKINGS

CONSENT FORM

NAME AND SURNAME
ID NUMBER
MALE / FEMALE
ADDRESS
CELL NUMBER
EMAIL ADDRESS
OCCUPATION
HOW DID YOU HEAR ABOUT US?
EMERGENCY NAME AND CONTACT NUMBER

MEDICAL QUESTIONAIRE:

CONDITION BEING TREATED?
DO YOU HAVE ANY MEDICAL, CHRONIC OR STRESS RELATED CONDITION? IF YES, PLEASE GIVE DETAILS
ARE YOU TAKING ANY MEDICATION OR SUPPLEMENTATION (INCLUDING ANABOLIC, DIURETIC, ANTICOAGULANT, ERGOGENIC, CANCER MEDICATION)
DO YOU SUFFER FROM CLAUSTROPHOBIA?
DO YOU HAVE EAR / SINUS PROBLEMS (INCLUDING WHEN FLYING OR DIVING)?
DOES ANY OF THE FOLLOWING APPLY TO YOU? PLEASE CIRCLE. (Pneumothorax, chronic sinusitis, upper respiratory infections, seizure disorders, emphysema with CO2 intoxication, high fever, history of thoracic or ear surgery, asymptomatic pulmonary blebs, congenital spherocytosis, pulmonary obstructive disease (e.g. asthma, empysema, obstructive bronchial disease, bullous pulmonary disease etc), eardrum perforation, ear blockages and / or ear conditions, asthma, optic neuritis, pregnancy, viral infections, cystic fibrosis, cancer
CURRENT USE OF ANY OF THESE DRUGS? (PLEASE CIRCLE) Cisplatinum, Disulfiram (Antabuse), Doxorubicin, Adriamycin, Bleomycin, Sulfamylon, Amphetamines, Nicorett-Nicoderm, Narcotic painkillers, Steroids,

mHBOT INDEMNITY, INFORMED CONSENT & TERMS AND CONDITIONS

mHBOT Session – Safety and Use of the Chamber

Cellular phones, headphones, tablets or laptops may be taken into the Biobarica (RevitalAir) 430 chamber. Due to the high combustibility of oxygen, lighters, cigarettes, aerosols, and flammable materials are strictly prohibited. Shoes must be removed prior to entering the chamber.

The optimal chamber temperature is 22°C. During pressurisation, the temperature may rise by 1°C to 2°C; therefore, the room temperature is maintained at approximately 20°C for comfort. During depressurisation, the chamber returns to room temperature.

Clients must inform the chamber operator prior to the session of any illness or condition including, but not limited to, colds, flu, congestion, sinus issues, allergies, ear trauma, or any other medical concerns.

If claustrophobia or a feeling of confinement is experienced at any time, the chamber operator must be notified immediately so that the inner valves can be opened and the chamber safely decompressed.

During pressurisation, mild to moderate ear discomfort may be experienced. This can usually be relieved by gently closing the mouth, pinching the nose, and blowing lightly until the pressure equalises. This technique should be performed gently and as often as necessary.

If effective ear equalisation is not achieved, the chamber operator must be informed immediately so that pressure can be adjusted or the chamber decompressed. Once discomfort has resolved, pressurisation may resume at a comfortable level.

Once the chamber is fully pressurised, no ear discomfort should be present. During decompression, mild ear discomfort may occur and can usually be alleviated by swallowing, yawning, or gently moving the jaw.

Mandatory Disclosure and Contraindications

The chamber operator must be informed prior to the session if any of the following conditions are present. A physician’s referral is required where indicated, and no session may be conducted without it:

• Untreated pneumothorax (absolute contraindication)
• Certain anti-cancer drugs (including doxorubicin, bleomycin, cisplatinum) (absolute contraindication)
• Chronic sinusitis or upper respiratory infections (relative contraindication)
• Seizure disorders (relative contraindication)
• Emphysema with CO₂ retention (relative contraindication)
• Uncontrolled high fever (relative contraindication)
• History of thoracic surgery (relative contraindication)
• History of ear surgery (relative contraindication)
• Asymptomatic pulmonary blebs (relative contraindication)
• Congenital spherocytosis (relative contraindication)
• Significant obstructive pulmonary disease (e.g. asthma, emphysema, bullous lung disease)
• Pregnancy
• Ear blockages or ear conditions
• Cystic fibrosis
• Stage 3 or Stage 4 cancer

Entering the Biobarica (RevitalAir) 430 chamber signifies a clear understanding and acceptance of the above recommendations and a declaration that no conditions exist that would contraindicate or place the client at risk during treatment.

 

 

Information

Hyperbaric oxygen therapy sessions are treated as private services and are not claimable from medical aid schemes. All packages carry an expiry period from the date of purchase. Sessions not cancelled at least four (4) hours in advance will be charged in full. Late arrivals may result in reduced session time.

Informed Consent

I hereby authorise OXYGEN THERAPY SA (Pty) Ltd and its directors, members, employees, agents, franchisees, or nominated representatives to administer mild hyperbaric oxygen therapy (mHBOT) using a Biobarica (RevitalAir) 430 chamber.

I confirm that I understand the pressurisation and depressurisation process and the associated risks. I acknowledge that the Biobarica (RevitalAir) system delivers mild hyperbaric oxygen therapy and is not classified as hyperbaric medicine.

I understand that mHBOT is a complementary therapy and does not replace primary medical treatment. No guarantees, claims, or assurances have been made regarding outcomes, healing, or cure.

I acknowledge that I have been informed of the potential risks, benefits, and foreseeable complications of mHBOT and that results may vary.

Prior to each session, I undertake to inform the operator if I have a cold, ear infection, sinus congestion, pulmonary symptoms, dizziness, or any condition outside my normal state of health.

During the session, I undertake to immediately inform the chamber operator of any discomfort, pain, ear pressure, or unusual symptoms. I understand that failure to report such discomfort may increase the risk of injury, and I agree that OXYGEN THERAPY SA (Pty) Ltd cannot be held liable for injury or complications arising from my failure to communicate discomfort or symptoms.

I confirm that I will attend sessions bathed, with wounds appropriately dressed. I confirm that I am free of uncontrolled high blood pressure or dizziness and that, if diabetic, I will have eaten within one hour prior to treatment.

I confirm that I have been given the opportunity to ask questions, that all questions have been answered to my satisfaction, and that I understand the information provided.

Indemnity and Disclaimer

I hereby indemnify and hold harmless OXYGEN THERAPY SA (Pty) Ltd, Biobarica, and all associated directors, members, employees, officers, franchisees, instructors, and agents from any liability, loss, claim, damage, injury, or death howsoever arising in connection with my participation in mild hyperbaric oxygen therapy, except where prohibited by law.

I accept this indemnity freely and voluntarily.

Payments, Packages, Cancellations and No-Shows

Once payment has been received by OXYGEN THERAPY SA (Pty) Ltd, no cash refunds will be made for unused sessions.

All packages are valid for a limited period from the date of purchase and are non-transferable. Packages may not be shared, sold, or redeemed by anyone other than the purchaser.

Package validity:

• 5-session package: valid for 2 months
• 10-session package: valid for 4 months
• Monthly package: valid for 20 sessions within a 31 day period

Late cancellations and no-shows (less than 4 hours’ notice) will be charged in full.

By signing this document, I confirm that I have read, understood, and agree to all terms, conditions, and indemnities set out above.

Name: ________________________________ Signature: __________________________

Date: _________________________________