Hyperbaric Oxygen Chamber

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Hyperbaric Oxygen Chamber - Waiver

Udara Bali, Jalan Pura Kramat, Seseh, Cemagi, 80351 Bali
info@udara-bali.com

Email *

First & Last Name *

Email *

Mobile Number with country code (WhatsApp) *

Name & Phone number of your Emergency Contact *

I understand that the Hyperbaric Oxygen Chamber therapy (HBOT) is intended to enhance, not replace any drugs or treatment program prescribed or recommended by a physician or health professional. I understand that the use of the chamber is not intended to diagnose, treat, or cure or prevent any disease. *

I understand

Required

HBOT has been reported to have beneficial effects for a wide range of conditions, yet I understand that there is no guarantee to any positive physical or emotional response to this therapy, and that I may not observe nor realize any immediate benefit from the HBOT treatment. *

I understand

Required

Udara Bali is a wellness hotel and not a medical facility. There is no medically trained staff on site for diagnosis or treatment. If I have any doubts, concerns or questions in regards to using the HBOT, I agree to seek and obtain medical advice. *

I understand

Required

I am aware that there might be side effects of using the Hyperbaric Oxygen Chamber such as discomfort in the ears and sinuses caused by pressure changes or dizziness. I am aware of the fact that HBOT may in rare cases cause ear drum perforation, oxygen toxicity, change of vision, or lung rupture. I agree to follow the instructions of the Udara staff to minimize any risks and prevent side effects during the use of HBOT. *

I understand and agree

Required

I am aware that certain conditions prevent me from using the HBOT. Please check the box if you currently have any of those conditions or tick the box "None of the above". *

Ear infection

Sinus infection

Cold or Flu symptoms

Pregnancy

Claustrophobia (fear of enclosed spaces)

High Fever

None of the above

Required

I am aware that certain diseases and/or a history of diseases and conditions may prevent me from using the HBOT. Please note if you have/experienced any of the following or tick "None of the above". *

Heart Disease, such as Heart Attack or Congestive Heart Failure

Pace Maker or Bypass

Panik attacks (especially from being in enclosed rooms)

History of Seizures, Schizophrenia or Epilepsy

Chronic obstructive pulmonary disease (COPD), untreated lung collapse (Pneumothorax), bullae of lung or mediastinal emphysema

Chronic or acute kidney conditions

Blood or circulatory disorders (such as uncontrolled high blood pressure, blood clots or deep vein trombosis)

Untreated rib fractures, open trauma to chest walls

Hollow pulmonary tuberculosis with hemoptysis, severe lung infections, bronchiectasis, severe emphysema

Bradychardia, sick sinus syndrome

Disinsertion

Active internal bleeding and hemorrhagic disease

None of the above

Other:

I agree not to carry any flammable products into the treatment room and adhere to a strict non-smoking policy, due to the risk of fire that comes with the use of concentrated oxygen. *

I agree

I am entering the chamber at my own risk. This waiver is intended to discharge in advance Udara Bali and its employees and business associates from and against all liability arising out of or connected in any way with my use of the HBOT. Knowing the risks involved and the contraindications related, I have read this entire form and fully understand and comprehend this waiver. By signing this agreement electronically, I am assuming any and all risk associated with the administration of the HBOT. *

I agree

Required

This waiver form is valid for individual sessions as well as packages (with session to be taken within a period of 6 months after purchase). Please notify the Udara staff about any changes of your health conditions before your next treatment.

Please type in your name to indicate electronic signature. *

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