OxyNova HyperBaric Therapy Consent Form

Name *

First

Last

IC Num (Last 4 Digits)

Questionaire Purpose

The purpose of this health questionnaire is to find out if you need a medical examination before a hyperbaric treatment.

Possible adverse effects and possible complications

What is the level of your health?

Claustrophobia

Claustrophobia refers to the discomfort or the feeling of being trapped in an enclosed place. It is possible that a hyperbaric chamber treatment triggers the symptoms related to claustrophobia. They can manifest in varying degrees. Nonetheless, it is very important to remain calm. If a treatment has to be stopped because the feeling of claustrophobia is too intense, one must still follow the depressurization procedure correctly.

To be done during a session:

Allow yourself some rest and indulge in a calm inducing activity such as sleeping, reading a book, meditating, or listening to your favorite music. The person inside the hyperbaric chamber can easily communicate with an attendant who is outside of the hyperbaric chamber when the latter approaches a window.

To do after the session:

After the completion of the treatment in the hyperbaric chamber, the treatment effect continues for approximately six more hours, because of the higher oxygen concentration in the user’s body. Feelings of relaxation, concentration, and greater energy as well as a pleasant feeling of tiredness can also be experienced. Effects of the treatment can be seen and felt right away or a day or two after the treatment. The number of necessary treatments may vary from one user to another depending on the reason for the consultation.

Please list your most concerning health care problems at this time (in order of importance to you)

Declaration

I declare that the information provided about my medical status is accurate and that I will inform the clinic/center or operator of any changes in my medical condition.

Consent For HyperBaric Therapy