H2 Methods Consent Form - Molecular Hydrogen (H2) Targeted Methods

Beneficiary of the Molecular Hydrogen (H2) Targeted Methods:

First Name *

Last Name

Birthdate *

Phone (mobile) *

Email Address *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Is the Beneficiary a minor? *YesNo

If the Beneficiary is a minor, add Parent/Legal Guardian information:

First Name

Last Name

Phone (mobile)

Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Today's Date *

I agree to terms and conditions of the Molecular Hydrogen (H2) Targeted Methods Trade Secret NDA that you can find and read by clicking the link below. *I agree

Molecular Hydrogen (H2) Targeted Methods Trade Secret NDA

Click here to read.

About the Consent Form

This Molecular Hydrogen (H2) Targeted Methods Consent Form (the “Consent Form”), signed at the date mentioned above and under signature(s), is made between the company I CHOOSE – I AM NOT A VICTIM CORP (the “Company”), represented by Gabriela Humailo Parker as the Founder/CEO and all the Beneficiaries of Molecular Hydrogen (H2) Targeted Methods or the Parent/Legal Guardian of the Beneficiary of the Molecular Hydrogen (H₂) Targeted Methods if the beneficiary is minor, collectively known as the “Parties.”

Molecular Hydrogen Therapy is currently considered experimental and is not formally regulated as a medical treatment in the US.

The Molecular Hydrogen (H2) Targeted Methods should be considered a complementary and/or alternative approach. They are not a replacement or substitute for conventional medical treatments, medical examinations, diagnosis, or treatments recommended by your doctor.

We do not offer any specific therapy, cure, or treatment for medical conditions.

The U.S. Food and Drug Administration (FDA) recognizes hydrogen gas as a food additive generally recognized as safe (GRAS – FDA GRN Nr. 520/Nov 28, 2014), and studies show inhalation of hydrogen gas is well-tolerated, including much higher concentrations. Molecular hydrogen gas has been used in deep-sea diving since 1943. Still, long-term studies are needed to assess the full safety of higher doses.

No upper safety limit for molecular hydrogen consumption has been established by regulatory agencies, such as the U.S. Food and Drug Administration (FDA).

The FDA considers products intended for inhalation, like H2 gas, not to be dietary supplements.

Under these circumstances, I understand that the practice of the Molecular Hydrogen (H2) Targeted Methods sessions is not an exact science and that no specific guarantees can or have been made concerning the expected results.

As with any recommended procedure, the goal of the Molecular Hydrogen (H2) Targeted Methods sessions is improvement, not perfection. I understand that my results may not be perfect and depend on my current health conditions and circumstances.

The number of Molecular Hydrogen (H2) Targeted Methods sessions recommended and the results experienced will vary among individuals and specific targeted areas.

Your Molecular Hydrogen (H2) Targeted Methods Goals

Which of these H2 Wellness goals speak to you? Select all that apply. *Clear My Mind & Boost My EnergyLook & Feel YoungerDetox & Heal My Body DeeplyMove Freely & Recover FasterEnhance My Fertility & VitalityBreathe Boldly & Live Fully

Is this your first H2 Experience? *YesNo

If not, please mention the previous H2 Experiences. (Enter NA if not applicable.) *

Do you have permanent makeup? *YesNo

Do you wear contact lenses? *YesNo

Do you wear hearing aids? *YesNo

Do you ever experience oily shine during the day? *YesNoOccasionally

Have you ever been diagnosed with skin cancer? *YesNo

Are you under a physician's care for a skin condition or other problems? *YesNo

If yes, for what condition or problems? (Enter NA if not applicable.) *

Are you currently having or will you soon have your menstrual period? *YesNoNA

Are you pregnant or think you may be pregnant? *YesNoNA

Are you taking birth control pills? *YesNoNA

If yes, what type? (Enter NA if not applicable.) *

Are you taking hormone replacement medication? *YesNo

If yes, what type? (Enter NA if not applicable.) *

Have you ever been diagnosed with a lung condition? *YesNo

If yes, what type? (Enter NA if not applicable.) *

Do you have asthma? *YesNo

Do you often experience stress? *YesNo

Do you have any allergies? *YesNo

If yes, what type? (Enter NA if not applicable.) *

Are you currently taking any medication? *YesNo

If yes, what type and for how long? (Enter NA if not applicable.) *

Have you ever used Accutane? *YesNo

If yes, for how long? (Enter NA if not applicable.) *

Do you have acne? *YesNo

If yes, for how long? (Enter NA if not applicable.) *

Do you experience frequent blemishes? *YesNo

If yes, for how long? (Enter NA if not applicable.) *

If you checked any of the medications above, for how long did you use them? (Enter NA if not applicable.) *

What results are you hoping today's Molecular Hydrogen (H2) Targeted Methods will help you achieve? *

Acknowledgment of Risks

I understand that I may have some discomfort, redness, swelling, itching, irritation, skin peeling, or flaking after a Molecular Hydrogen (H2) Targeted Methods session. I have discussed these risks with the Molecular Hydrogen (H2) Targeted Methods practitioner and understand them thoroughly.

If I experience any pain or discomfort during the Molecular Hydrogen (H2) Targeted Method session, I will immediately inform the Molecular Hydrogen (H2) Targeted Method practitioner to adjust the products and/or techniques to my level of comfort.

I understand that the Molecular Hydrogen (H2) Targeted Methods should not be construed as a substitute for medical examination, diagnosis, or treatment.

I also understand that the Molecular Hydrogen (H2) Targeted Methods practitioner is not qualified to perform, diagnose, prescribe, or treat any physical or mental illness and that nothing said during the session should be construed as such.

Because certain methods should not be performed under certain medical conditions, I understand that the Molecular Hydrogen (H2) Targeted Methods practitioner reserves the right to refuse to perform any session on anyone whom he/she deems to have a condition for which Molecular Hydrogen (H2) Targeted Methods are contraindicated.

I affirm that I have stated all my known medical conditions and answered all questions honestly.

I agree to keep the Molecular Hydrogen (H2) Targeted Methods practitioner updated as to any changes in my medical profile before the session and understand that there shall be no liability on the Molecular Hydrogen (H2) Targeted Methods practitioner's part should I fail to do so.

Cancellation and no-show policy

You must cancel the appointments at least 24 hours in advance. If you cancel your appointment in less than 24 hours before the scheduled time or do not attend, a fee of 100% of the cost of the Molecular Hydrogen (H2) Targeted Method reserved session will be charged.

This policy ensures that we can accommodate other clients and maintain the schedule efficiently.

Privacy Statement

I understand how my personal and medical information will be used and protected.

Your personal and medical information will be kept strictly confidential and will only be used for your Molecular Hydrogen (H2) Targeted Methods improvement and care.

This information will not be shared with third parties without your explicit consent, except as required by law or in the case of a medical emergency. All records will be stored securely, and reasonable precautions will be taken to protect your information from unauthorized access or disclosure.

You have the right to request access to your records at any time.

Consent Statement

I voluntarily consent to participate in the Molecular Hydrogen (H2) Targeted Methods session(s), and I certify that I have read and fully understand the above consent. I have been given ample opportunity for discussion, and all of my questions have been answered to my satisfaction.

I have read and understood the above information, and I voluntarily consent to the Molecular Hydrogen (H2) Targeted Methods session(s). I release the Molecular Hydrogen (H2) Targeted Methods practitioner, the Company, and the facility from all liabilities of the Molecular Hydrogen (H2) Targeted Methods session(s) I voluntarily consent to participate.

This constitutes the full disclosure and supersedes any previous verbal or written disclosures. Neither the Company nor the Molecular Hydrogen (H2) Targeted Methods practitioner is responsible for any injury, allergic reactions, or any skin abrasions as a result of the services performed on me.

Signature

By signing below, I acknowledge that I have read and understood this Molecular Hydrogen (H2) Targeted Methods Consent Form and agree to the terms and conditions stated herein.

The Beneficiary of the Molecular Hydrogen (H2) Methods Signature: *(Enter NA if the Beneficiary is a minor)

Printed Name *

Signature Date *

If the Beneficiary is a minor, the Parent/Legal Guardian Signature: *(Enter NA if not applicable.)

Printed Name (Enter NA if not applicable.) *

Signature Date *