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HBOT CONSULTATION FORM

HBOT Client Paperwork

Please fill out the following form in order to participate in our Hyperbaric Oxygen Therapy.

First Name

Last Name

Date of Birth

Email

Street Address

City

Postal / Zip code

Street Address Line 2

Contact Telephne Number

Emergency Contact Name

Relationship

Emergency Contact Number

Employer

Job Title

How Did You Hear About Us?

Known allergies (food, drugs, vaccines or environmental)

Current Health Conditions (Please list in order of priority)

Current Medication (Perscriptions, Over The Counter Drugs, Vitamins, Herbs, Homeopath, Remedies, ect) Please state dosage

PLEASE ANSWER THE FOLLOWING QUESTIONS ON YOUR PAST OR PRESENT MEDICAL HISTORY WITH YES OR NO. If you are not sure, PLEASE TICK

Could you be pregnant, or are you attempting to become pregnant?

Have You Ever Had, Or Do You Currently Have? * Required

Lung disease, any form

Emphysema

Pneumothorax/Collapsed Lung

Chest surgery

Heart failure

High Blood Pressure

Any electronically implanted medical device (i.e., pacemaker, deep brain stimulator)

Any diseases or conditions involving ears or sinus or surgical interventions

Difficulty in clearing ears during airplanes or pressurized environments like diving

Claustrophobia

Epilepsy/Seizures

Diabetes

Cataracts

None of the above

Are you presently taking prescription medications for any of the above questions? If so, please specify:

I testify that the information I have provided is true and accurate to the best of my knowledge, and I have been explained the potential risks for any of the above questions that I answered “yes” to and have been given the opportunity to speak to my doctor or a healthcare provider about this.

I, hereby consent and authorize staff at to administer hyperbaric oxygen therapy (HBT) to me. In doing so, I hereby acknowledge the following: • I understand HBT is FDA cleared the following 15 medical conditions: Decompression sickness, gas embolism, CO & cyanide poisoning, selected aerobic and anaerobic soft tissue infections, gas gangrene, osteomyelitis, intracranial abscess, management of fungal disease, radiation injury to tissue, exceptional blood loss/anemia, crush injury/compartment syndrome, ischemia reperfusion injuries, skin grafts and flaps, healing in selected problem wounds thermal burns, sudden idiopathic sensorineural hearing loss, altitude sickness.

OFF LABEL USE: If I am using HBT for any medical condition outside of the FDA cleared indications listed above, the FDA considers this to be off label. FDA does not recommend using off-label HBT, particularly if it is being used as first line therapy or in replacement of an FDA approved treatment. Additionally, this requires a signed physician form/prescription from my doctor to undergo HBT for my condition.

I have been given the opportunity to ask any question I might have regarding HBT and/or OT (oxygen therapy), and the staff has answered all my questions.

I have informed the staff of my current health status, all current medications, and therapies, and I agree that it is my responsibility to keep the staff aware of any changes in my condition, medication, or therapies, for EVERY SESSON.

I have been informed that I may refuse treatments at any time, or even terminate a treatment while in the chamber, and exit the chamber in minutes.

I will follow the instructions of the hyperbaric chamber staff and I will inform the staff of ALL concerns during the treatment, including but not limited to; pain, nausea, diarrhea, dizziness, visual changes, ringing or other noises in the ears, unusual smells, fear or anxiety reaction, unusual sweating, changes in heart rhythm, hiccups, chest pain, faintness, mood changes, difficulty breathing, or any discomfort.

I have read and understand the FAQ and will comply with its instructions.

The benefits of HBT may be much greater if I follow a healthy lifestyle, which includes non-smoking, weight control, exercise, proper nutrition, and stress management. m-

If any unforeseen conditions arise during this treatment, I do hereby authorise/request the staff to perform such additional procedures and/or to render such treatments as may be deemed necessaryat that time.

FULL NAME

DATE

SIGN HERE

Thanks for submitting!

CONTACT US

ADDRESS:

16 Dudley Road,

New Brighton, Wirral, CH45 9JP

CONTACT US:

info@thenorthwestwellbeinghub.co.uk

0151 294 5953

Company Number: 14081302

Terms & Conditions

© 2024 by Debbi Kruger

The NorthWest Wellbeing Hub

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