Informed Consent for Hyperbaric Oxygen Therapy
  • If you selected “Yes” to any of the above, you must notify the staff prior to hyperbaric exposure. I understand that failure to provide honest and accurate answers to all questions, including the above potential medical contraindications, may result in personal injury.

  • I hereby verify that neither Dr. Stapleton nor any of her agents has 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 the 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 and thoroughly understand the information provided and hereby agree to be treated with hyperbaric oxygen treatments. I also understand that insurance does not cover Hyperbaric Oxygen Therapy for the treatment of off-label conditions and that I will be personally responsible for the cost of these treatments for my condition(s).

  • MM slash DD slash YYYY
  • This form collects personal information so we can contact you to discuss your request. Take a look at our privacy policy for the full story.