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Oxygenome — Equipment Inquiry & Qualification Form
OXYGENOMEMachinery & Equipment Rental LLC · Dubai, UAE · oxygenome.ae
STRICTLY CONFIDENTIAL
Ref.
Equipment Inquiry & Qualification Form
Hyperbaric Chambers · Hard Shell & Soft Shell · Medical & Wellness
Important — Please read carefully before completing This form is a mandatory precondition to the release of any documentation, pricing, brochure or technical specification by Oxygenome. All fields marked with ✱ are required. Incomplete, inaccurate or knowingly false submissions will be declined without reply. By submitting this form you accept the Non-Disclosure & Non-Circumvention Agreement set out in the final section, which is binding upon submission.
Qualification
Details
Equipment
Agreement
Applicant qualification
Please answer each question accurately. All information is required and will be verified.
Are you inquiring as ✱
Please select one.
Are you inquiring ✱
Please select one.
Your end client is ✱
Please select one.
Intended use ✱
Please select one.
Business use — select all that apply ✱
Select at least one.
Is this for an existing or a future facility? ✱
Please select one.
Contact & organization
Please provide accurate and verifiable details.
Your details
Required.
Required.
Required.
Valid email required.
Your company details
Required.
Title as shown on your business card
Required.
Company domain only — no free email providers
Valid business email required.
Enter a valid website (e.g. https://www.yourcompany.com).
UAE trade license number
Required.
DHA / MOH / DOH — enter NA if not applicable
Required.
Business licensing
UAE trade license
Required.
DHA / MOH / DOH — enter NA if not applicable
Required.
End client details
Required.
Required.
Registered business name the end client operates under
Required.
Enter a valid website (e.g. https://www.client.com).
UAE trade license number
Required.
DHA / MOH / DOH — enter NA if not applicable
Required.
Required.
Required.
Equipment & installation
Details of the equipment you are looking for and where it will be installed.
Installation & facility
Selection required.
Required.
Clinic / facility address or zone
Required.
Selection required.
Selection required.
Briefly: licensing process started? funding in place?
Required.
Equipment
Chamber type — select all that apply ✱
Select at least one.
Optional — briefly describe what you have in mind so we can advise.
Required.
Required.
Required.
Required.
Required.
Declaration & agreement
Final step. This is binding upon submission.
The undersigned declares that all information provided is accurate, complete and truthful as at the date of submission. Any false statement or intentional omission voids the request immediately and releases Oxygenome from any obligation to respond.
You must tick all boxes.
Non-Disclosure & Non-Circumvention Agreement
NCNDA — binding upon submission

1. Parties. Between Oxygenome Machinery & Equipment Rental LLC (Dubai, UAE — the "Disclosing Party") and the signatory of this form, acting in their own name or for the entity / client identified herein (the "Receiving Party").

2. Confidential information. All pricing, technical data sheets, brochures, specifications, protocols, case studies, and supplier or manufacturer identities communicated by the Disclosing Party in any form in connection with this inquiry.

3. Non-disclosure. The Receiving Party shall not disclose, reproduce or forward confidential information to third parties without prior written consent, and shall use it solely to evaluate the project described in this form.

4. Non-circumvention. For three (3) years from submission, the Receiving Party shall not — directly or indirectly, alone or through any affiliate, agent, client or related party — contact, solicit, negotiate or transact with any manufacturer, supplier or source identified, named or introduced by Oxygenome (including any party whose identity appears in or can be inferred from any document provided), nor bypass, circumvent or exclude Oxygenome from any resulting transaction. Any breach entitles Oxygenome to the full commission or margin it would have earned, plus damages and legal costs.

5. No competitor / intelligence gathering. The Receiving Party declares it is not acting in the interest of a competitor nor to gather commercial intelligence.

6. Term, law & acceptance. Obligations survive three (3) years regardless of outcome. Governed by the laws of the UAE; disputes subject to the courts of Dubai. Electronic signature below constitutes full acceptance.

Signature required.
Required.
Required.
You must accept the NCNDA.
You must tick all the declaration boxes above before submitting.
Strictly confidential · Each submission generates a unique reference and email confirmation.
Oxygenome Machinery & Equipment Rental LLC · Dubai, UAE · oxygenome.ae
Inquiry received