Patient Information Form - Rocky Mountain Hyperbaric Institute

Patient Information Form

First Name*
Last Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Date of Birth*
MM slash DD slash YYYY
Emergency Contact*
Name
Emergency Contact Phone
Primary Care Physician*
Name
Primary Care Physician Phone
Referred by
Presenting complaints*
Have you had HBOT before?*
- Yes
- No
If yes, how many treatments?
If yes, have you had complications from HBOT treatment?
- Yes
- No
Do you smoke?*
- Yes
- Never
- Former
What is your daily average diet like and how is the quality of your sleep?
List medical history (surgery, etc.) including allergies:*
List all medications you take (including over-the-counter and supplements):*
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.
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