Informed Consent for Hyperbaric Oxygen Therapy * I understand that the process involved in the procedure, its risks and the potential side effects of hyperbaric oxygen will be explained to me before my first treatment. I understand that hyperbaric oxygen is considered the primary therapy for several conditions and is accepted by the American College of Hyperbaric Medicine, however, the therapy with which I will be treated may be characterized as “investigational” and not generally accepted by the mainstream medical community. I am being informed of the potential side effects of hyperbaric oxygen therapy, including, but not limited to: * Barotrauma to the ears and/or sinuses; otitis (fluid in the ears) – I understand that pressure changes can result in mild to severe pain in the ears, sinuses, or teeth. Middle ear barotrauma is the most common adverse effect. I have been explained the pressure equalization techniques and if I feel any pain or discomfort, I will alert the staff immediately. Cerebral Air Embolism and Pneumothorax/Pulmonary Over Pressurization – I understand that decompressions are slowly and carefully timed to prevent this from occurring and that I should breathe in a relaxed manner at all times and not hold my breath during decompression. Confinement Anxiety (claustrophobia) - I understand I may experience some claustrophobia in the chamber and will alert the staff if this should occur. Fire Hazard (extremely remote possibility) - I understand the remote possibility of a fire hazard and I will not bring any prohibited items into the hyperbaric chamber. If I have any questions about whether or not a particular item is allowed, I will ask a technician. Oxygen Toxicity Seizures – I have been explained the rare risk of oxygen toxicity and understand that treatment protocols will be determined to prevent this from occurring. Temporary Visual Changes (nearsightedness) – I understand the possibility of temporary visual changes. Potential Medical Contraindications to Hyperbaric Oxygen Therapy - Do you currently have any of the following? Cold or allergy symptoms / Fever Pregnancy Inability to equalize middle ear pressure Meniere’s Disease Heart disease or vascular disease Anemia, polycythemia, or other blood disease Implanted medical device Are you taking Doxorubicin(Adriamycin) 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).First Name* Last Name* Phone*Email* Date* 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.* I understand by submitting this form I agree to the privacy policy. * I understand that Rocky Mountain Hyperbaric Institute will use this information to contact me regarding my inquiry. CAPTCHA
