Name *

First Name

Last Name

Checkbox

Tick if you are experiencing or have

Collapsed Lung

COPD

Emphysema

Chest or ear surgery

Current sinus, ear, or upper respiratory infection

Pregnancy

Diabetes mellitus

Convulsive disorder e.g epilepsy

Optic neuritis / sudden blindness

Recent Cancer Chemotherapy

Current Malignancy

Anaemia or any blood disorder

Congenital spherocytosis

Current disulfiram (Antabuse) therapy

Traumatic Brain Injury

Concussion

Stroke

A concern about alzheimers

Memory Issues

Autism

Depression

Recent dental treatment

Long Covid

An interest in anti-ageing benefits

An interest in stem cell growth

An interest in Cognitive enhancement

None of the above

Declaration *

By submitting this form to Wellington / Manawatu Hyperbarics, I declare that:

I have stated my medical history, completely and honestly.

I will inform the clinic if my answers were to change.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I am aware that finance is possible from $70 per week if I qualify for it, to help finance my treatment. *

Yes - I am aware of this, please tell me more about how I can take advantage of this, if I decide to undergo treatment,

No - that will not be necessary.