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.