I hereby request the use of the following confidential communication channels when communicating information related to my personal health or treatment. This request supersedes any prior request for confidential communication channels I have made.

I understand that my Health Insurance Carrier may not pay for some or all of the services rendered by Santa Monica Hyperbaric Oxygen, and that they are not contracted with, or aligned to provide services for any insurance companies at this time. I agree to pay for services rendered at the time of the service.

I CERTIFY THAT ALL THE ANSWERS AND INFORMATION PROVIDED BY ME ABOVE ARE ACCURATE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

I, [ First Name ] [ Last Name ], hereby consent and authorize the hyperbaric oxygen therapy staff at Santa Monica Hyperbaric Oxygen, a private wellness clinic (the “Company”), to administer Hyperbaric Oxygen Therapy (hereby referred to as “HBOT”) to me at a designated pressure, duration, frequency and number of sessions. In doing so, I hereby acknowledge the following:

I have read, understand and agree to the Treatment Guide as detailed below. I understand the nature, purpose, and potential risks of doing HBOT and agree to proceed with therapy as outlined by Santa Monica Hyperbaric Oxygen. I understand that Santa Monica Hyperbaric Oxygen is not contracted with any insurance carrier, nor aligned to provide services for any insurance companies at this time, and that I am responsible for the full cost of treatment. I understand that HBOT may or may not help my condition, enhance my health, reduce pain, or otherwise affect changes, and that Santa Monica Hyperbaric Oxygen makes no claims or guarantees as such. I have asked a representative of Santa Monica Hyperbaric Oxygen any questions I had regarding HBOT and its risks and potential benefits and have been provided answers to my satisfaction.

In consideration for the use of the Company’s HBOT facilities at the agreed upon price, I expressly accept and assume all risks attendant to HBOT and agree to defend and indemnify the Company and its staff and employees for any claims or demands arising from my use of HBOT unless those claims arise from gross negligence or intentional conduct on the part of the Company or its staff.

I have informed Santa Monica Hyperbaric Oxygen of my current health status, all current medications, and therapies, and I agree that it is my responsibility to keep my Santa Monica Hyperbaric Oxygen updated as to any changes in my condition, medication, or therapies. I have submitted all appropriate paperwork and documentation (if requested) regarding my current health status and history, therapies not associated with Santa Monica Hyperbaric Oxygen, current prescriptions, and medications. I am aware of contraindicated conditions, medications, and therapies to HBOT as explained/detailed to me by a representative or in the Health History Questionnaire intake I completed. I have disclosed these items to Santa Monica Hyperbaric Oxygen in order to avoid associated complications with my HBOT treatment.

I understand that once therapy begins, it is my responsibility to communicate any issues that may occur, with the attending technician. I will inform the technician immediately if I experience pain, nausea, diarrhea, dizziness, visual changes, ringing or other noises in the ears, unusual smells, fear or anxiety reaction, unusual sweating, changes in heart rhythm, hiccups, chest pain, faintness, mood changes, difficulty breathing, or any discomfort. I understand that based on any of these circumstances, I may need to terminate my session early by signaling the technician, and possibly seek medical attention. I understand that the technician may determine to end the session early on my behalf, and authorize them to do so. I understand that Santa Monica Hyperbaric Oxygen does not have medical personnel on staff, and that a staff member may need to request medical assistance for me in case of emergency. I understand that my vitals (such as heart rate) are not monitored in the HBOT chamber and that the technician will only be monitoring me visually. If I am in need of emergency medical assistance and unable to request it myself, I authorize Santa Monica Hyperbaric Oxygen to request such assistance on my behalf.

I certify that I have read, or have been read to me this consent and fully understand its contents, and hereby consent and agree to the terms.

In an effort to provide superior care and personalized customer service, as well as to provide competitive rates, the following procedures have been established. These policies will ensure a satisfying experience for all our clients and guests. 

Personal Belongings: For your convenience a storage area is provided for your personal items. Santa Monica Hyperbaric Oxygen is not responsible for lost or stolen items.

Scheduling: To allow for full convenience and flexibility, we recommend you schedule your services in advance. A valid credit card is required to reserve your appointment, however your card will not be charged until time of treatment, unless another payment method is chosen.

Arrivals: All first time clients must arrive at least 15 minutes prior to their scheduled appointment. Arriving early will allow you sufficient time as we require new Clients to fill out health history information and treatment consent forms. 

Late Arrivals: Scheduling is designed to allow the correct amount of time to complete your service. In consideration to others, your service must end on time so the next client's appointment can begin as scheduled. If you are not able to be on time we will complete as much of your treatment as possible; however with some treatments it may be necessary to reschedule your appointment. This could result in a charge of the full value of your service. 

Cancellations: We understand sometimes you need to change or reschedule your appointment. We kindly ask that you provide us with a 24-hr prior notification for Tuesday-Saturday appointments and a 48-hr prior notification for Monday appointments. A "no show" and any appointment cancelled without proper notification will result in a charge of 100% of the scheduled treatment. 

Payment: Santa Monica Hyperbaric Oxygen accepts Visa, MasterCard, Amex, cash and gift certificates. All service sales are final. Due to the nature of the Hyperbaric Oxygen treatments, please keep in mind there are no guaranteed outcomes and results can vary. All professional fees are to be paid in full prior to or at the time of treatment. The client is responsible for all service charges. 

Termination and Referrals: Santa Monica Hyperbaric Oxygen reserves the right to refuse service at any time. I understand that Santa Monica Hyperbaric Oxygen is providing HBOT at their discretion and may terminate my therapy at any time for any reason, and will charge me only for the sessions completed.

This Company-Client Arbitration Agreement ("Agreement") is entered into by and between [ First Name ] [ Last Name ] ("Client") on the one hand, and SANTA MONICA HYPERBARIC OXYGEN, LLC and its directors, officers, shareholders, partners, entities, employees, and contractors ("Company"), on the other. Each party herein may be referred to as a "Party", and all of the parties mentioned herein are collectively referred to as the "Parties".

Article 1: Agreement to Arbitrate. It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompletely rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.  

Article 2: All Claims Must be Arbitrated. Any dispute, claim, or controversy exceeding the jurisdictional limit of the California small claims court arising out of or relating to services, care, treatments, products, or medications provided, prescribed, recommended, and/or sold by Company to Client, including whether the claims asserted are arbitrable, will be referred to and finally determined by arbitration at JAMS in accordance with the JAMS International Arbitration Rules, with the rights of the parties under this Agreement to be governed by and construed in accordance with the laws of the State of California, exclusive of conflict or choice of law rules. Such disputes, claims, or controversies include but are not limited to claims for medical malpractice, loss of consortium, wrongful death, emotional distress, and punitive damages. Filing of any action in any court by the Company to collect any fee from the Client shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Company, any fee dispute, whether or not the subject of any court action, shall be resolved by arbitration. It is the intention of the Parties that this Agreement shall be binding on each and every Party whose claims may arise out of or relate to the treatment, service, or prescriptions and health supplements (compounded or otherwise) provided and/or distributed by Company to Client or purchased by Client from Company. It is the explicit intent of the Parties hereto that this Agreement shall be binding on any and all claims by Client's spouse, children (whether born or unborn at the time of the occurrence giving rise to any claim), heirs, agents, estates, or trusts. In the case of any expectant mother, the term "Client" herein shall mean and refer to both the expectant mother and the unborn child or children.
 
Article 3: Procedures and Applicable Law. Procedures and Applicable Law. Arbitration under this Agreement shall be commenced by a Party making a written demand to all other Parties for arbitration. Within fifteen (15) days after commencement of arbitration, each party shall select one person to act as arbitrator, and the two so selected shall select a third arbitrator within thirty (30) days of the commencement of the arbitration. If the arbitrators selected by the parties are unable or fail to agree upon the third arbitrator within the allotted time, the third arbitrator shall be appointed by JAMS in accordance with its rules. The third arbitrator shall serve as the arbitration chair ("Chair"). All arbitrators shall serve as neutral, independent, and impartial arbitrators. Each Party to the arbitration shall pay such Party's pro rata share of the Chair's expenses and fees, together with other expenses of the arbitration incurred or approved by the Chair, with each Party bearing its own counsel fees and witness fees, and other expenses incurred by such Party for such Party's own benefit. The Parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request of the same to the Chair by either Party. The Parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional Party in a court action, and such intervention and joinder any existing court of action against such additional person or entity shall be stayed pending arbitration. The Parties agree that provisions of California law application to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any Party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05; however, depositions may be taken without prior approval of the Chair. 
 
Article 4: General Provisions. All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to
arbitration. 

Article 5: Revocation. This arbitration agreement may be revoked by written notice delivered to Company within 30 days of signature. It is the intent of this arbitration agreement to apply to all medical services rendered any time for any condition. 

Article 6: Confidentiality. The Parties shall maintain the confidential nature of the arbitration proceeding and any award, including the hearing, except as may be necessary to prepare for or conduct the arbitration hearing on the merits, or except as may be necessary in connection with a court application for a preliminary remedy, a judicial challenge to an award or its enforcement, or unless otherwise required by law or judicial decision. 

Article 7: Retroactive Effect. The Parties intend this arbitration agreement to be retroactive and to cover services rendered by Company to Client before the date it is signed (including, but not limited to, emergency treatment).

Article 8: Severability. If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

Article 9: Punitive Damages. In any arbitration arising out of or related to this Agreement, the arbitrators are not empowered to award punitive or exemplary damages, except where permitted by California statute, and the Parties waive any right to recover any such damages.

Article 10: Attorneys’ Fees to Prevailing Party. In any arbitration arising out of or related to this Agreement, the arbitrators shall award to the prevailing party, if any, the costs and attorneys' fees reasonably incurred by the prevailing party in connection with the arbitration. If the arbitrators determine a Party to be the prevailing party under circumstances where the prevailing party won on some but not all of the claims and counterclaims, the arbitrators may award the prevailing party an appropriate percentage of the costs and attorneys' fees reasonably incurred by the prevailing party in connection with the arbitration.  I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I received a copy. 

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.