Onmega Dolphin therapy Centre.
Mares Hotel Seaside Dolphinpark
48700 Marmaris / Mugla / Türkei
Tel : +90 252 455 406 4
Fax: +90 252 455 243 3
info@dolphin-therapy.org 		Onmega Consulting & Health Tourism Ltd.
Carsi Cad. Dikmen Center
No: 28 D: 5
48300 Fethiye / Mugla / Türkei
Tel : +90 252 614 67 16
Fax: +90 252 614 70 62
info@dolphin-therapy.org
 

If you are interested in our Dolphin Therapy Programme please fill out this form below and press the send button. Besides, please send us a photo of the patient. If our doctor needs the hospital or doctor reports and anemnesis for detailed information to decide about dolphin therapy according to illness we may also request them later.

 APPLICATION FORM FOR DOLPHIN ASSISTED THERAPY

 *obligatory
Name, Forename
Country
Your Age
Your contact E-mail address
Address
Tel.
Fax.
Communication Language
Prefferred Communication method
Number of accompaying persons   1 2 3 4 5
Any other children Travelling ?   Yes No
If yes How Many ?   1 2 3 4
Their birthdates(DDMMYY) ?(Necessary)
When do you plan to join therapy program?
In which hotel you plan to stay?
PATIENT INFO
Full Name of the patient
Male/ Female   Male Female
Birthplace and Date
Patient's Native Language
 
Weight in Kgs
 Height in Cms
 
Complete Name and address, phone/fax, e-mail of the patient's Doctor/Specialist.
Date of last medical diagnos and anamnesis(Both please send per e-mail or fax Nr.+90 252 455 2433)
 OTHER SPECIAL REQUESTS AND NEEDS ?
Request Date
 
QUESTIONS
1. The diagnosis of your patient and reason for his/her handicap?  
1.1. Development of handicap  
Is there Epilepsy?   Yes No  
(If there is no epilepsy proceed to question 2)
  
In case of Epilepsy:  
   1.a. International Epilepsy Code  
   1.b At which age did epilepsy began?  
   1.c. What caused the epilepsy?  
   1.d. What causes the epilepsy now?
   Circumstances/Physical activity emotions/    Climate etc.		  
   1.e. Is there any record of epilepsy in the family?  
   1.f. Please Describe the sympthoms of the epilepsy  
   1.g. How often does epilepsy occur?
   Daily/weekly/Monthly/Yearly
  
   1.h. How long do the fits last?  
   1.i.  Is the patient conscious during fits?  
   1.j. What further negative symptoms accompany
   the fit during or afterwards?		  
   1.k. What is the Trend exploration? No difference Better Worse  
   1.l. Please list all medication.  
   1.m. Are the parents able to provide immediately
    medication?		  
   1.n. What type of other help must immediately be
    provided?		  
   
2. Does the patient require a Wheelchair/special help?  
   2.a. Can the patient even using wheelchair walk or take some stair cases even with support?  
3. Is special food necessary?   Yes No  
   3.a.If "Yes", which type?  
4. Is the patient afraid of sea water?  
5. Does the patient like animals?   Yes No  
  5.a. which ones?  
6. Does the patient experience with water?   Yes No  
7. Can the patient swim?   Yes Yes,with arm rings etc. No  
8 Can the patient Hear?   Yes No  
9. Can the patient see?   Yes No  
10. Does the patient wear spectacles?   Yes No  
   10.a. If "Yes", which Dioptre strength?  
11. Past illnesses (Last three years)  
12. Is the patient under medicated therapy?   Yes No  
12.a. If "Yes", which?(dosage details)  
13. Has the patient undergone any operations?   Yes No  
   13.a. If "Yes", please state reason, type and date
    of operation with exact descripton.		  
   13.b. Course and duration of Recuperation  
   13.c. Are contraindications present?   Yes No  
      13.c.1.  If "Yes", which type?  
14. Has the patient had special Therapies? Is there any therapy being carried out?  
15. Present mental and physical condition?  
16. Can the patient keep his/her head upright?   Yes No  
17. Can the Patient walk?   Yes Yes, with support No  
   17.a. By limited ability, please extrapolate.
    (How many metres or stairs etc.)		  
18. Can the Patient strech his/her arms and grip     objects?   Yes No  
SOCIAL/EMOTIONAL
19.Can the Patient make and maintain eye contact?   Yes No  
20. Will the Patient interact with others?
  
21. Does the patient experience anxiety when separated from parents?  
22. Can the Patient acclimate the changes in the environment?  
BEHAVIOR    
23.Is the Patient aggressive with others?
   Yes No  
24. Does the Patient exibit any self injurious behavior     (scratching, headbanging, biting, etc.)?
  Yes No  
   24.a. If "Yes", in which form?  
25. Does the Patient have tantrums?   Yes No  
   25.a. If "Yes", how does this manifest itself?  
LANGUAGE
26. Can the Patient babble or vocalize (make sounds )?   Yes No  
27. Can the Patient communicate with speech?   Yes No  
28. Does the Patient respond her/his name?   Yes No  
29. Can the Patient follow simple commands or insructions  (i.e. come, go, sit)?   Yes No  
30. Is the Patient aware her/his environment?   Yes No  
31. Does the Patient react, or is sensitive to sun, warmth or coldness?   Yes No  
   31.a. If "Yes", describe these Reactions  
32. What do you expect of Dolphin therapy?  

Liability Declaration

You herewith free Onmega Consulting Ltd Health Tourism, their personnel, sub-contractors and the crew of the Dolphinarium from all liability whatsoever, this includes injury, side-effects, subsequent injury and similar as a result of the treatment of the patient with the dolphins and all related activities.

You declare that should any of the above, during or as a result of the Therapy, take place, no legal action will be undertaken against Onmega Consulting Ltd Health Tourism, the Therapists, sub-contractors or the crew of the Dolphinarium. The participation in the Therapy is voluntary and entirely at your own risk.

 Certificate of Travel

A medical Certificate is required stating that the patient is fit to travel on a flight to Turkey and that the patient is medically capable of taking part in Dolphin therapy.

 Obligations

In sending your details to us for processing with the intention to apply for Therapy you are in no way obligated and no charges will be incurred; this is part of our service with regard to our Therapy offer and is entirely free of charge and free of obligations.

By despatching your Application you automatically confirm the details you have presented. You also agree with the rules, liability declaration and the regulations concerning medical Certificates. Please confirm that the details you have provided are to the best of your knowledge and that they have been given with the consent of the patient or person responsible for the patient. Furthermore you consent to our personnel and Therapists seeing and working with this information and any documents.

Your privacy is protected as laid down by German law.

With despatch of this form the sender confirms his acceptance of the above statements and that all details given are correct..

I confirm and accept the above statement       Yes  
 
 
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