Hydrogen Hygiene Targeted Methods™ Consent Form
H2 Methods Consent Form
Beneficiary of the Hydrogen Hygiene Targeted Methods™
Full Name: *______________________________________
Date of Birth: *____________________________________
Address: *________________________________________
Phone (mobile): *__________________________________
Email: *__________________________________________
Date: *_____________________________
Parent/Legal Guardian if the Beneficiary is a minor
Full Name: *______________________________________
Address: *________________________________________
Phone (mobile): *__________________________________
Email: *__________________________________________
Date: *______________________________
About the H2 Methods Consent Form
This Hydrogen Hygiene Targeted Methods™ Consent Form (the “Consent Form”), signed at the date mentioned above and under signature(s), is made between the company MHIH TM LLC (the “Company”), represented by Gabriela Humailo Parker as the Founder/CEO, and all the Beneficiaries of Hydrogen Hygiene Targeted Methods™ or the Parent/Legal Guardian if the Beneficiary of Hydrogen Hygiene Targeted Methods™ is a minor, collectively known as the “Parties.”
Molecular Hydrogen Therapy is currently considered experimental and is not formally regulated as a medical treatment in the U.S.
Consequently, Hydrogen Hygiene Targeted Methods™ should be considered a complementary approach. They are not a replacement or substitute for conventional medical treatments, medical examinations, diagnoses, or other 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 (H2)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 at 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 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 Hydrogen Hygiene 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 Hydrogen Hygiene 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.
All results are unique to each person and reflect the effects of molecular hydrogen’s chemistry inside their body after using Hydrogen Hygiene Targeted Methods™.
The number of Hydrogen Hygiene Targeted Methods™ sessions suggested, and the results experienced, will vary among individuals and specific targeted areas.
Your H2 Wellness Goals
Which of these H2 Wellness goals speaks to you? Select all that apply.
☐ Clear My Mind & Boost My Energy
☐ Look & Feel Younger
☐ Detox & Heal My Body Deeply
☐ Move Freely & Recover Faster
☐ Enhance My Vitality, Fertility, Virility, or Hormonal Wellness
☐ Breathe Boldly & Live Fully
Your Health Statement
Is this your first molecular hydrogen (H2) experience? ☐ Yes ☐ No
If not, please mention your previous H2 experiences.
Do you have permanent makeup/tattoos? ☐ Yes ☐ No
Do you wear contact lenses? ☐ Yes ☐ No
Do you wear hearing aids? ☐ Yes ☐ No
Do you ever experience oily shine during the day? ☐ Yes ☐ No ☐ Occasionally
Have you ever been diagnosed with skin cancer? ☐ Yes ☐ No
If yes, please write the details about the diagnosed skin cancer.
Are you under a physician’s care for a skin condition or other problems? ☐ Yes ☐ No
If yes, for what condition or problems and for how long?
Are you currently having or will you soon have your menstrual period? ☐ Yes ☐ No ☐ NA
Are you pregnant, or do you think you may be pregnant? ☐ Yes ☐ No ☐ NA
Are you taking birth control pills? ☐ Yes ☐ No ☐ NA
If yes, what type and for how long?
Are you taking hormone replacement medication? ☐ Yes ☐ No
If yes, what type and for how long?
Have you ever been diagnosed with a lung condition? ☐ Yes ☐ No
If yes, when and what lung condition?
Do you have asthma? ☐ Yes ☐ No
Do you often experience stress? ☐ Yes ☐ No
Do you have any allergies? ☐ Yes ☐ No
If yes, what type and for how long?
Are you currently taking any medication? ☐ Yes ☐ No
If yes, what type and for how long?
Have you ever used Accutane? ☐ Yes ☐ No
If yes, for how long?
Do you have acne? ☐ Yes ☐ No
If yes, for how long?
Do you experience frequent blemishes? ☐ Yes ☐ No
If yes, for how long?
How much plain water do you drink daily?
☐ 1-2 glasses
☐ 3-4 glasses
☐ 5-6 glasses
☐ 7-8 glasses
☐ More than 8 glasses
Which of these medications are you currently using, or have you used in the past?
☐ Azelex ☐ Differin ☐ Renova ☐ Retin-A ☐ Tazorac ☐ Glycolic Acid ☐ Alpha Hydroxy Acids ☐ Other ☐ None
For how long did you use the medications checked above?
Which of these products are you currently using on your face?
☐ Soap☐ Cleanser☐ Toner ☐ Scrub ☐ Mask ☐ Cream ☐ Moisturizer ☐ Sunscreen ☐ Other ☐ None
Which of these skin conditions have you ever experienced?
☐Flakiness ☐ Tightness ☐ Dryness ☐ Sensitivity ☐ Scars ☐ Rosacea ☐ Other ☐ None
What results are you hoping Hydrogen Hygiene 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 Hydrogen Hygiene Targeted Methods™ session. I have discussed these risks with the Hydrogen Hygiene Targeted Methods™ practitioner and understand them thoroughly.
If I experience any pain or discomfort during the Hydrogen Hygiene Targeted Methods™ session, I will immediately inform the Hydrogen Hygiene Targeted Methods™ practitioner to adjust the products and/or techniques to my level of comfort.
I understand that the Hydrogen Hygiene Targeted Methods™ should not be construed as a substitute for medical examination, diagnosis, or treatment.
I also understand that the Hydrogen Hygiene 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 Hydrogen Hygiene Targeted Methods™ practitioner reserves the right to refuse to perform any session on anyone whom they deem to have a condition for which Hydrogen Hygiene 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 Hydrogen Hygiene 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 Hydrogen Hygiene Targeted Methods™ practitioner or the Company’s part should I fail to do so.
Cancellation, Rescheduling, and No-Show Policy
Please give us at least 24 hours’ notice if you need to cancel or reschedule your appointment.
If you cancel or reschedule your appointment in less than 24 hours of the scheduled time or do not attend, a fee of 100% of the cost of the Hydrogen Hygiene Targeted Methods™ reserved session will be charged.
We appreciate your understanding of this policy, which ensures we provide the best care on time to all our clients, allowing us to accommodate other clients and maintain the schedule efficiently.
Privacy Statement
I understand how my personal and medical information will be used and protected as follows:
– My personal and medical information will be kept strictly confidential and will only be used for my Hydrogen Hygiene Targeted Methods™ improvement and care.
– My information will not be shared with third parties without my 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 my information from unauthorized access or disclosure.
– I have the right to request access to my records at any time.
H2 Methods Consent Statement
I voluntarily consent to participate in the Hydrogen Hygiene 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 my questions have been answered to my satisfaction.
I have read and understood the above information, and I voluntarily consent to the Hydrogen Hygiene Targeted Methods™ session(s). I release the Hydrogen Hygiene Targeted Methods™ practitioner, the Company, and the facility from all liabilities of the Hydrogen Hygiene Targeted Methods™ session(s) I voluntarily consent to participate in.
This constitutes the full disclosure and supersedes any previous verbal or written disclosures. Neither the Company nor the Hydrogen Hygiene 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 Hydrogen Hygiene Targeted Methods™ Consent Form and agree to the terms and conditions stated herein.
The Individual Granting Permission
Beneficiary of the Hydrogen Hygiene Targeted Methods™ or the Parent/Legal Guardian if the Beneficiary of the Hydrogen Hygiene Targeted Methods™ is a minor.
Signature: * ___________________________________
Printed Full Name: *___________________________________
As the: *
☐ Beneficiary of the Hydrogen Hygiene Targeted Methods™
☐ Parent/Legal Guardian if the Beneficiary of the Hydrogen Hygiene Targeted Methods™ is a minor
Signature Date: *______________________