Safety Questionnaire

1) Have you ever personally suffered from epilepsy or had a seizure? *

Yes

2) Do you have a family history of epilepsy or seizures? *

Yes

3) Are you pregnant? *

Yes

4) Do you have severe insomnia or are you currently sleep deprived? *

Yes

5) Have you ever had a stroke, head injury or brain surgery? *

Yes

6) Have you consumed alcohol or recreational drugs in the last 24 hours? *

Yes

7) Do you take medication? (Some medications taken for prolonged periods, or in high doses, can lower the threshold for seizures. Please see the supplementary medication information) *

Yes

INFORMED CONSENT: PLEASE READ ALL STATEMENTS CAREFULLY

8) I confirm that whilst I have never suffered from epilepsy or seizures, I understand there is a statistical chance that I could be sensitive to flickering light and that this could lead to a seizure.

9) I confirm that I understand the Roxiva lamp is NOT a medical or psychological therapy and is not intended as a treatment or remedy for any condition.

10) I confirm that I have read the form carefully and answered the questions truthfully.

11) I confirm that I understand the nature of Roxiva and session that I am about to experience.

12) I confirm that I sign this Form of my own free will, by completing the details in full below.

Full Name

Phone *

Email *

Emergency Contact Name *

Emergency Contact Number *

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