Burley 208-219-4926

Twin Falls 208-410-3578

Chattanooga 423-750-6422

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I hereby request and give consent to Oxygen Health Spa, to the staff, to provide Hyperbaric Oxygen Therapy for the following condition(s):

I understand and agree to the use of HBOT is controversial and experimental for some conditions.

I believe that HBOT has the potential to improve my health and quality of life.

I have been informed of other treatment options for the above condition(s) and these options have been explained to me my satisfaction.

I understand that the benefits of HBOT are much greater if I follow a healthy lifestyle including proper diet and nutritional supplementation.

I understand that this therapy consists of treatment in a chamber that exposes my entire body to oxygen up to three times the normal atmospheric pressure.

I have been informed that HBOT frequently involves multiple weekly treatments and some conditions may require many more treatments to realize the full potential of benefits.

I understand that it is my option to stop this treatment at any time without incurring any further expense.

 I understand and agree that it is necessary to strictly adhere to the technician instructions to maintain safety throughout my time of HBOT.

I understand and agree that treatments will be limited to not more than 2, one hour sessions per day, separated by at least 4 hours because excessive levels of oxygen for prolonged periods can be irritating and may cause permanent changes to the lungs.

I understand that past medical history of spontaneous collapsed lung, air trapped in a lung, or inability to equalize pressure in the ears can increase the risk of complications during HBOT.

I understand that the potential for complications can be minimized by my adherence to the instructions provided by the staff.

I understand and agree that some prior medical conditions can make HBOT more hazardous.

I will inform the staff provider if any of the following exist or existed: emphysema, chest, or ear surgery, lung bullae or bleb, collapsed lung, chronic bronchitis or an acute viral infection such as a bad cold or flu.

I understand that the oxygen environment in the HBOT chamber greatly increases the flammability of materials.

I understand that fire prevention is a major concern and that my strict adherence to the HBOT safety guidelines is essential to prevent a fire.

I have read and understand the HBOT guidelines that were provided to me.

I understand and agree that under no circumstances will I bring matches, lighters or any combustible or incendiary devices into the HBOT chamber.

I understand and agree that Oxygen Health Spa does not accept medical insurance for treatments. I understand and agree the costs for HBOT therapy may not be reimbursed by my medical insurance.

I agree that there have been no warranties, assurances or guarantees of successful treatment made to me.

I have considered the alternatives (including my right to decline HBOT at any time) I have read and understand the information contained in this document and the information provided to me through conversations with and literature provided by Oxygen Health Spa Staff.

I have had the opportunity to question the staff at Oxygen Health Spa with respect to HBOT and the procedure utilized and all my questions have been answered to my full satisfaction.

I understand the potential risks of HBOT and I believe the potential benefits outweigh the potential risks. Therefore, I request that HBOT be provided to me.

I have read this consent and I am fully aware of the potential risks associated with Hyperbaric Oxygen Therapy (HBOT) and agree to undergo treatment provided at Oxygen Health Spa.  

INFORMED CONSENT FOR HYPERBARIC OXYGEN TREATMENT

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