Online Application

PATIENT REGISTRATION
Are you a Veteran?
- Yes
- No
Veterans, please contact us for more information, and to determine qualification for our Veterans Program.
Thank You
Phone:
208-480-3062
Patient's Name*
First Last
Phone*
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
Patient's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is Billing Address Different from Physical Address?*
Yes
No
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact*
First Last
Relationship to Emergency Contact*
Emergency Contact Phone*
Emergency Contact Email*
Referred By
Is referrer a:*
Doctor
Friend
Relative
Other
Condition being treated*

PATIENT HISTORY
Patient's Marital Status
Married
Single
Other
Patient's Height*
Patient's Weight*
Does Patient Have a Caregiver?*
Yes
No
Caregiver's Name
First Last
Caregiver's Phone
Referring Physician*
First Last
Diagnosis / Indication*
Any Special Requirements Needed
Current Medications

Allergies

*If you do not have any allergies, enter "None" in the field*
Previous Medical History
Have you ever been diagnosed or currently have any of the following conditions?
Chest Trauma
Congestion
Heart Condition
Diabetes
High or Low Blood Pressure
Cold or Fever
Eye Problems / Cataracts
Ear / Sinus Problems
Un-healing Wounds
Claustrophia
Please explain or list current conditions or concerns you may have that could affect your treatment

DISCLOSURE AND INFORMED CONSENT
By clicking YES, below you request and authorize, that you or the person whom you are a legal guardian for, be included as a patient for the use of Hyperbaric Therapy, and that a successful outcome cannot be guaranteed.

I understand that the procedures and risks related to Hyperbaric Therapy to be the following:

1) I will be placed in a Hyperbaric Chamber that will be pressurized with compressed air to a pressure of up to three (3) atmospheres absolute, which is the amount of pressure used for treatment. During therapy in the Mono-place Chamber I will rest in a reclining position on a gurney that slides into the steel and acrylic chamber. I will be able to communicate with the qualified technician during my entire treatment.

2) I have been advised that while dangers are minimal, it is possible that I may experience discomfort to my ears, sinuses or teeth due to the change in barometric pressure. If such discomfort occurs, I will notify the technician, who will stop the treatment until the problem has been resolved. I understand that some individuals who experience discomfort with their ears may require a myringotomy. An ear, nose and throat specialist generally performs this as an outpatient procedure. I understand that if this procedure is required, I will miss hyperbaric treatments until the procedure is done.

3) If I have any lung abnormalities, it is possible that during decompression, I may experience problems due to the trapping of air in some part of the lungs. This may result in an arterial gas embolism, collapsed lung, or emphysema. While these problems may be serious, my physician is aware of these potential problems and does not believe that any pulmonary abnormalities exist.

4) I understand that if I am diabetic, I may be slightly more vulnerable to oxygen toxicity than a non-diabetic. However, I understand that I must eat shortly before coming for treatment and I will have a source of glucose available during treatment.

5) I understand that positive results from Hyperbaric Treatment cannot be guaranteed. I understand that as in the administration of any medication, in some instances this treatment may not have the expected or anticipated benefits. However, the desired and expected results have been explained, together with the rationale for the use of hyperbaric therapy in my particular case.

6) I understand that hyperbaric therapy is usually considered to be an adjunctive treatment and is used in conjunction with other medical treatment. Therefore, I will not discontinue my other medication and treatment of my medical condition without my doctor's specific instructions. All intravenous medication will be interrupted during the actual hyperbaric treatment, but the IV line(s) need not be removed if properly capped.

7) I understand there are risks involved in any procedure or treatment, and it is not possible to guarantee or give assurance of a successful result.

8) I understand that it is not uncommon for the eyes to undergo minor refraction during an extended series of hyperbaric treatments. I understand that this change occurs more frequently in individuals over the age of 50 than to those who are under the age of 50. I understand that these changes are usually temporary, and that after discontinuing treatment the eyes usually return to their previous condition.

9) I understand that after an extended series of treatments I may notice numbness and tingling in my fingertips. I understand this is a temporary reaction and usually disappears after hyperbaric treatments are discontinued.

10) I understand that the use of certain medications is contraindicated during treatment with hyperbaric oxygen therapy, and I agree to inform the facility personnel of all medications that I am currently taking, or have taken in the last six months.

11) I consent to the photography, filming, viewing or videotaping of the treatment of myself for educational use.

12) I am satisfied with my understanding of the nature of the procedure or treatment and all additional questions have been answered.

BY CLICKING 'YES' BELOW, YOU AGREE THAT YOU HAVE READ AND UNDERSTAND THE EXPLANATIONS PROVIDED ON THIS PAGE AND VOLUNTARILY AGREE TO PARTICIPATE IN THE TREATMENT PROGRAM.
*
Yes

AUTHORIZATION TO RELEASE INFORMATION & CONSENT FOR TREATMENT
The nature, purpose, benefits and risks of all care and service have been explained to me.

I authorize the release of Patient Health Information (PHI) in order to carry out the treatment.

I understand that my pre-dive physical and x-rays can be charged to my health insurance carrier.

I understand that insurance rarely pays for HBOT delivered in a freestanding center.

I understand that you accept the following forms of payment:

Personal Checks

Cash

Major Credit Cards (Visa, MasterCard, Discover)

I understand that you will assist me in any way possible to provide the necessary paperwork needed to submit a claim to my insurance carrier. I understand that you are unable to file claims for insurance coverage and you are not able to deliver HBOT based on the possibility of insurance reimbursement.

I understand that PAYMENT IS EXPECTED AT THE TIME OF SERVICE.
By clicking 'yes' below you consent to care and treatment by Hyperbarics of Sun Valley, as may be prescribed by same and/or dictated by professional standards.

*
Yes

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Hyperbaric Health and Wellness Foundation is a registered 501(c)3 nonprofit. We make HBOT treatment affordable for those who face mental and physical health challenges.

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