HOCATT New Patient Form Step 1 of 2 50% Name* First Last Date of Birth MM slash DD slash YYYY Age Height Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*ContraindicationsThere are certain circumstances during which certain modalities of the HOCATT should not be used. Please indicate with a check mark if any of the following conditions apply to you. Steam/FIR Sauna* Fever Bleeding tendencies ex. hemophiliacs Active bleeding (from an injury) Menstruation Elevated blood alcohol or drug levels Excessive 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 (past 30 minutes) Little or no sleep the night before Known heart conditions ex. heart failure, heart blockages, recent heart attack, etc Uncontrolled and/or malignant high blood pressure Hypotension (keep temperature below 38 celsius) Taking blood pressure medication NONE APPLY TO ME CO2/Carbonic Acid* Hypotension Taking blood pressure medication NONE APPLY TO ME Transdermal Ozone/Insufflation* Thyrotoxicosis/hyperthyroidism G6PD deficiency (Favism)/hemolytic anemia Organ transplant patient, ex. taking immune suppression medication Cutaneous porphyria (transdermal only) Vitiligo (transdermal only) NONE APPLY TO ME Frequency Specific Microcurrents* Pregnancy Epilepsy and/or seizures Electrical implants ex. pacemaker, cochlear implant, intrathecal pump, insulin pump, etc Known heart conditions ex. heart failure, heart blockages, recent heart attack, arrhythmias, etc. Blood clots/DVT's or strokes Recent surgery (past 72 hours) Implanted metals ex. 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 NONE APPLY TO ME Have you consumed at least half your body weight (pounds) of water (in ounces) today prior to your session? e.g. if you weigh 150 pounds, drink at least 75 ounces of water.* Yes No, but I will have some now please Please list ALL current daily medications, herbs and/or supplements and dose:*Are there any other any other medical conditions you have that your practitioner/ technician should be aware of?* It is recommended that ALL CLIENTS, regardless of heart condition, see their primary doctor before using the HOCATT or FSMs. You should inform your doctor that they will be using a temperature- controlled steam and FIR sauna, and your doctor should perform the regular health-checks (e.g. take blood pressure, etc.) HEART CONDITIONS & ELDERLY CLIENTS Elderly Clients and those with known heart conditions MUST consult their cardiologist about using steam and FIR saunas, as well as Frequency Specific Microcurrents (FSM) if you would like to add an FSM program to your HOCATT session. You need an EKG (not older than 12 months) and you need to be CLEARED to use a sauna by your cardiologist before doing a HOCATT session. Your cardiologist may recommend a safe temperature range, as well as a heart rate limit that may not be exceeded. Your cardiologist might also clear you for FSM should you want to add it to your HOCATT session. The HOCATT Plus has a heart rate monitor, so that you can monitor your heart rate throughout the session. You can also ask the HOCATT practitioner/ technician to set a heart rate limit (e.g. 120 beats/min). If your heart rate exceeds this limit, then the whole system will shut down (ending the session immediately).DETOX REACTION It is very important to drink plenty of water before and after a HOCATT session, as well as throughout the rest of the day and the days that follow. Drinking water helps your body to flush out toxins. It is important to note that detoxifying the body too fast, especially if there are many toxins present, can overload the body’s avenues of elimination. These include the kidneys, liver, colon, lymph system, skin and lungs. When these organs are impaired, then even mild detoxification methods can overload the remaining elimination organs. Overloading these systems can result in a detox reaction or “cleaning crisis”. You may experience anything from flu-like symptoms to a skin rash. It is the body’s way of trying to get rid of the toxins. While ultimately a detox reaction is a sign of a good thing, it can still be an unpleasant experience. It is much easier to get through when you support your body’s normal elimination systems. When these organs are working well, and there is sufficient water and nutrient intake, then most detox reactions pass quickly, and sometimes even go unnoticed! This is why it is very important to drink plenty of water and take supplements, to help support the liver, kidneys, colon and other elimination systems. Be sure to do this if you find yourself experiencing a detox reaction.IMPORTANT LEGAL INFORMATION & DISCLAIMERS THE HOCATT IS NOT A MEDICAL DEVICE. IT HAS NOT BEEN EVALUATED OR APPROVED BY THE FDA OR NDF, AND WE DO NOT CLAIM ITS INTENDED USE TO TREAT, CURE, PREVENT OR DIAGNOSE ANY DISEASE OR MEDICAL CONDITION. Though we will be glad to supervise the use of this equipment, we do not aim to treat, cure, prevent or diagnose any disease or medical condition. This information should not be used as a substitute for professional medical advice. Under US law, only a medical doctor may “treat” illness and disease with a medical origin, such as cancer. This law is to protect you from the possibility that, while you are receiving HOCATT sessions, an illness which may need orthodox medical attention could be getting worse. Furthermore, it is important to note that we cannot be held responsible for any health issues you may have, and we cannot be held responsible for deterioration of any ailments that you have. The physiological effects and efficacy Transdermal Ozone and Oxygen, Whole Body Hyperthermia, Far Infrared, CO2 / Carbonic Acid, Frequency Specific Microcurrents, Essential Oil Infusions, and Photon Light and Colors have been documented widely and is publically available in literature. These systems are only ever intended to be “in addition” to any medical treatment that you need or are receiving. Please note that any treatment you are receiving from your Doctors should continue whilst you enjoy the HOCATT. The manufacturer or any marketing agent cannot accept liability for any injury or fatality in relation to the use of this equipment. The client agrees to use this product at his/her own risk, and a parent/guardian takes responsibility for the fragile/minors. It is the client’s responsibility to acquaint him/herself with any risks associated with their physical or medical condition, as well as any side effects or risks associated with the medications they are taking, and to consult a medical practitioner if in doubt.DeclarationI 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 technician liable for any illness, injury or worsening of any pre-existing condition that results from using this equipment. I have read the above information (both pages) and understand completely what I have read.If fainting occurs, an ambulance will be called. If you choose not to have one called, tick this box. Do not call ambulance Name First Last Date Signed* MM slash DD slash YYYY Signature* Refund policy All refunds are subject to an internal processing fee of 10% of remaining value.