
OUR POLICIES
By signing this form, I acknowledge that, with respect to services rendered by Heavenly Salt Therapy, and their employees and agents, I understand the following:
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We are an out-of-network provider for services within this practice; We do not participate in any insurance panels, and do not accept assignment from any insurance company. Consequently, you are responsible for payment in full at time of service and charges are determined by us.
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For Hyperbaric Chamber Use:
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Due to the sensitivity of other patients and staff, refrain from wearing perfume, after-shave, or essential oils.
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You will not be allowed in if you smell of tobacco or cannabis smoke. It is recommended that you do not smoke or use tobacco products for 3 days prior to a treatment. Nicotine, a byproduct of cigarette and cigar smoke, causes constriction of blood vessels and HBOT stimulates the growth of blood vessels. Smoking during a course of therapy would counteract the beneficial effects of treatment.
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I have carefully read this form, which is printed in English, and acknowledge that English is a language I read and understand, and that I understand the form. I do not feel rushed or impaired, nor am I under the influence of a sedative or sleep-inducing medication.
I accept and agree to all of the terms above. I am free to refuse or withdraw my consent and to discontinue participation in any treatment, service, or research at any time without fear of reprisal against or prejudice to me. No representations, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. I may request and receive a copy of this form from the Practice. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.