HOCATT™ Intake Form

Name *

First Name

Last Name

Phone Number *

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Steam / FIR Sauna

Fever

Bleeding tendencies e.g. hemophiliacs

Active bleeding (from an injury)

Menstruation

Elevated blood alcohol or drug levels

Excessiv caffeine intake

Pregnancy

Children (<18 years)

Taking medications that impair sweating and/or increase the health risks from heat exposure

Heat insensitivity

Low blood sugar levels (empty stomach)

Recently eaten a heavy meal (in past 30 mins.)

Little or no sleep the night before

Known heart conditions e.g. heart failure, heart blockages, recent heart attack, etc.

Uncontrolled and/or malignant high blood pressure

Hypotension (keep temperature < 38° C)

Taking blood pressure medication

Transdermal Ozone / Insufflation

Thyrotoxicosis / Hyperthyroidism

G6PD deviciency (Favism) / hemolytic anemia

Organ transplant patient, i.e. taking immune suppression medication

Cutaneous porphyria (transdermal only)

Vitiligo (transdermal only)

CO2 / Carbonic Acid

Hypotension

Taking blood pressure medication

Frequency Specific Microcurrents

Pregnancy

Epilepsy and/or seizures

Electrical implants e.g. pacemaker, cochlear implant, intrathecal pump, etc.

Known heart conditions e.g. heart failure, heart blockages, recent heart attack, arrhythmias, etc.

Blood clots/DVT's or strokes

Recent surgery (past 72 hours)

Implanted metals e.g. pins, plates, screws, joint replacements, mechanical heart valves, metal stents, or staples in blood vessels, etc.

An injury (where you may still be bleeding)

Broken, injured, swollen, inflamed or infected skin on the hands or feet

Cancerous / malignant tissue

High-Intensity PEMF

Pregnancy

Epilepsy and/or seizures

Elevated blood alcohol or drug levels

Electrical implants e.g. pacemaker, cochlear implant, intrathecal pump, insulin pump, etc.

Implanted metals e.g. pins, plates, screws, joint replacements, dental implants, mechanical heart valves, metal stents, or staples in blood vessels

Breast implants

Known heart conditions e.g. heart failure, heart blockages, recent heart attack, arrhythmias, etc.

Active bleeding or bleeding tendencies i.e. hemophilia, bleeding wound, or menstruation

Grave's disease

Organ transplant patient, i.e. taking immune suppression medication

You will have consumed at least half your body weight (pounds) of water (in ounces) prior/day of your session. e.g. if you weigh 150 pounds, drink at least 75 ounces of water.

Yes

DECLARATION *

I am aware that every safety measure will be undertaken by staff, and that this may include my refusal if deemed unsafe. The information that I have given is true and complete, and I would like to go ahead with the HOCATT session at my own risk. I understand what will occur during a session, and I take personal responsibility for my choice in receiving sessions. I shall not hold the manufacturer, any marketing agent, physician/practitioner or HOCATT technician liable for any illness, injury or worsening of any pre-existing condition that results from using this equipment. By typing your full name below, you acknowledge reading the information on this form and completing the questions accurately. You acknowledge and accept the terms of use and understand completely what you have read.

First Name

Last Name

If fainting occurs, an ambulance will be called. If you choose not to have one called, tick this box.

Tick this box to NOT have ambulance called in the event of fainting

Date *

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