I Understand that Dr. is recommending one or multiple insta-venous and/or
subcutaneous activated oxygen (Ozone) therapies for me. This therapy, although not used typically
in conventional medicine and unapproved by insurance companies’ actual have a tract record of
safety and efficacy. Dr. has taken continuing medical education workshop and
seminars that emphasize and each procedure for sale application of these therapies. He is certified in
Ozone Therapy.
I understand that these treatments are intended to enhance cellular oxygen utilization, blood flow,
cellular healing and pain relief. By way of protein-like molecules called cytokines, these therapies
are intended to stimulate immune system activity. I understand that depending on the type and dose
of activated oxygen therapy. I receive, some effects maybe more anti-inflammatory and anti
microbial, where as others may promote cellular regeneration and immune modulation.
All of these therapies, to the extent that they enhance tissue oxygenation and blood flow, are
intended to relive pain and inflammation, up regulate antioxidant enzyme defense. I understand this
research has been documented in peer reviewed medical and scientific journals and that the
therapy(ies) advocated, are not considered dangerous, when administered within the limits and
standards of a trained medical practitioner.
I understand that should I currently be in any of the following conditions, one or more of these
therapies may not be appropriate for me: Pregnancy, Thyrotoxicosis, Hemophilia, Porphyria, and
extremely low platelet count.
Also, I understand that as with the any intravenous therapy, I might experience:
- Transient hypoglycemic (low blood sugar).
- Headache and/or light-headache Ness.
- Local swelling.
- Slight hemolysis if I have a G6PD deficiency.
Alternatives to this therapy have been discussed with me and include:
- Various Pharmaceuticals.
- IV therapies, without ozone.
I understand Dr. and/or any representative of make no
warranties or guarantees about these therapies with respect to my condition. I do; however, I
understand the board application of these therapies to sub optimal oxygenation state, which is the
underlying abnormality in many chronic conditions. I further acknowledge that it is my right to
cease activated oxygenation therapy at any time. Finally, I understand that my insurance carrier will
likely not pay for active oxygen therapies.
With full awareness of the above facts and considerations
I Give my consent to Dr. Hani Chidiac
and/or anyone representing for giving me one mor multiple treatment of
activated oxygen therapies
I understand and agree that I am financially responsible for the payment I made for
that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the
date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months
period. I agree that my payment made is non-refundable or non-transferable post this period.
"I agree that healthcare provider(s) involved in my care at this facility will access my health information
through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab
Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies ".
I declare that I have read and fully understood all points in this consent and that all of my questions were
answered to my satisfaction and I take the full responsibility of my decision in this consent.
Patient Name & Signature :
Doctor/Therapist Name & Signature :
Witness Name & Signature :
Parent or Gaurdian Name (if patient is minor) :
Date :
Consent to be photographed and published
I, , consent to be photographed and published on Social
media, by while before and after the procedure. I further authorize that the
photographs may be published for any purpose and in any form.
