I hereby authorize George F. Daviglus, M..D and Luis G. Rodas PA-C, the Neubauer Hyperbaric Neurologic Center,and its medical staff to provide hyperbaric oxygenation therapy for-

I will be administered hyperbaric oxygen therapy as treatment for the following condition(s):

1. I understand and have been explained the process involved in the procedure, its risks, and the potential side effects of hyperbaric oxygenation. I understand that hyperbaric oxygen is considered the primary therapy for several conditions and is accepted by the American College of Hyperbaric Medicine, however the therapy to which I will be treated for may. be characterized as "investigational" and not generally accepted as effective by the medical community.

2. I have been informed of the potential side effects of hyperbaric oxygenation therapy, including but not limited to:

A. Barotrauma to the ears and/or sinuses; otitis (fluid in the ears) - I understand that I may feel discomfort in my ears and/or sinuses due to increased pressure and that techniques to alleviate it will be demonstrated by the medical staff. (similar to airplane flight)

B. Pneumothorax over pressurization - I understand that decompressions are slowly and carefully timed to prevent this from occurring and that I should breathe in a relaxed manner at all times and not hold Iny breath during decompression. (never seen at this center)

C. Confinement Anxiety (claustrophobia) - I understand that I may feel claustrophobic.(mild Rx for some)

D. Oxygen Toxicity Seizures - I have been explained the rare risk of oxygen toxicity and understand that treatment protocols will be determined to prevent this from happening.(only 6 out of30,000 Txs)

E. Temporary Visual Changes (nearsightedness) - I understand the possibility of temporary visual changes. (need for reading glasses disappears temporarily)

F. Fire hazard (extremely remote possibility) - I understand the remote chance of fire hazard

I hereby verify that neither George Daviglus M.D., Luis G. Rodas PA-C, or the Neubauer Hyperbaric Neurologic Center, or on of its agents, has NOT made any promises or assurances to me regarding the hyperbaric oxygen therapy that I agree to in respect to its efficacy in curing or alleviating any condition for which I will be treated.

By signing this document below I constitute my full agreement and understanding of the foregoing and that I am fully satisfied with the information provided to me by the physician/physician assistant onsite and thoroughly understand the information provided and hereby agree to be treated with hyperbaric oxygenation treatments.