Hyperbaric Oxygen Consent Form
Please review and complete this form to provide your informed consent for hyperbaric oxygen therapy.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any of the following conditions?
*
Lung disease (e.g., COPD, asthma)
Ear problems (e.g., infections, surgery, hearing loss)
Seizure disorders
Claustrophobia
None of the above
Please list any known allergies
*
Please list any current medications
*
Have you received hyperbaric oxygen therapy before?
*
Yes
No
I have read and understand the information provided about hyperbaric oxygen therapy. I consent to undergo this procedure and have had the opportunity to ask questions.
*
Submit Consent
Submit Consent
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