Online Reservation

In order to make your reservation, please read and fill in the form below carefully, and send it to us.
It is important to fill in all the necessary information so that we can process your request smoothly.

 

We will be replying to you regarding your request usually within 24 hours, with your reservation details.
Once you receive the email, please make sure to reply to us with necessary corrections.
Upon your reply with acknowledgement, we will confirm your reservation.

 

If you do not hear from us in 24 hours,
please email us to info@primescuba-ishigaki.com, or call us at +81 980 87 5980.

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Please read carefully before signing.
This is a statement in which you are informed of some potential risks involved in scuba diving and of
the conduct required of you during the scuba training program. Your signature on this statement is
required for you to participate in the scuba training program. In addition, if your medical condition
changes at any time during your scuba programs it is important that you inform your instructor
immediately.
 
Read this statement prior to signing it. You must complete this Medical Statement, which includes the
medical questionnaire section, to enroll in the scuba training program. If you are a minor, you must
have this Statement signed by a parent or guardian. Diving is an exciting and demanding activity. When
performed correctly, applying correct techniques, it is relatively safe. When established safety
procedures are not followed, however, there are increased risks.
 
To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be
strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All
body air spaces must be normal and healthy. A person with coronary disease, a current cold or
congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should
not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking
medications on a regular basis, you should consult your doctor and the instructor before participating
in this program, and on a regular basis thereafter upon completion. You will also learn from the
instructor the important safety rules regarding breathing and equalization while scuba diving. Improper
use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under
direct supervision of a qualified instructor to use it safely.
 
If you have any additional questions regarding this Medical Statement or the Medical Questionnaire
section, review them with your instructor before signing.
 
 
Divers Medical Questionnaire
To the Participant:
The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before
participating in recreational diver training. A positive response to a question does not necessarily
disqualify you from diving. A positive response means that there is a preexisting condition that may
affect your safety while diving and you must seek the advice of your physician prior to engaging in dive
activities.
 
Please answer the following questions on your past or present medical history with a YES or NO. If you
are not sure, answer YES. If any of these items apply to you, we must request that you consult with a
physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical
Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to your physician.
 
– Could you be pregnant, or are you attempting to become pregnant?
– Are you presently taking prescription medications? (with the exception of birth control or
anti-malarial)
– Are you over 45 years of age and can answer YES to one or more of the following?
– currently smoke a pipe, cigars or cigarettes
– are currently receiving medical care
– have a high cholesterol level
– high blood pressure
– have a family history of heart attack or stroke
– diabetes mellitus, even if controlled by diet alone
 
Have you ever had or do you currently have…
– Asthma, or wheezing with breathing, or wheezing with exercise?
– Frequent or severe attacks of hayfever or allergy?
– Frequent colds, sinusitis or bronchitis?
– Any form of lung disease?
– Pneumothorax (collapsed lung)?
– Other chest disease or chest surgery?
– Behavioral health, mental or psychological problems (Panic attack, fear of closed or openspaces)?
– Epilepsy, seizures, convulsions or take medications to prevent them?
– Recurring complicated migraine headaches or take medications to prevent them?
– Blackouts or fainting (full/partial loss of consciousness)?
– Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?
– Dysentery or dehydration requiring medical intervention?
– Any dive accidents or decompression sickness?
– Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?
– Head injury with loss of consciousness in the past five years?
– Recurrent back problems?
– Back or spinal surgery?
– Diabetes?
– Back, arm or leg problems following surgery, injury or fracture?
– High blood pressure or take medicine to control blood pressure?
– Heart disease?
– Heart attack?
– Angina, heart surgery or blood vessel surgery?
– Sinus surgery?
– Ear disease or surgery, hearing loss or problems with balance?
– Recurrent ear problems?
– Bleeding or other blood disorders?
– Hernia?
– Ulcers or ulcer surgery ?
– A colostomy or ileostomy?
– Recreational drug use or treatment for, or alcoholism in the past five years?
 
The information I have provided about my medical history is accurate to the best of my knowledge. I
affirm it is my responsibility to inform my instructor of any and all changes to my medical history at
any time during my participation in scuba programs. I agree to accept responsibility for omissions
regarding my failure to disclose any existing or past health condition, or any changes thereto.