Hyperbaric Oxygen Chamber Therapy Consent Form
I, _______________________________________________________ hereby consent to and authorize the Sacramento Naturopathic Medical Center to perform or have performed on me, Hyperbaric Oxygen Therapy (HBOT). I know and realize that Hyperbaric Oxygen Therapy might call for more than one treatment and I hereby authorize this facility to perform the number of HBOT which in their opinion are necessary to treat my condition. I hereby acknowledge that I know and understand the nature and purpose of HBOT. Additionally, the doctors have explained to me the consequences, risks as listed below, and alternatives to receiving HBOT. They have given me the opportunity to ask questions regarding the risks, benefits and options. The doctors have answered my questions to my satisfaction.
Risks of HBOT:
- Ear drum discomfort/rupture
- Gas embolism (bubbles in the bloodstream)
- Increased cataract growth rate
- Increased risk of fire
- Lung over pressurization/collapsed lung (pneumothorax)
- Myopia (nearsightedness) reversible after treatment
- Oxygen toxicity- central nervous system (seizures/fits)
- Pulmonary irritation
Have you had, or do you have any of the following:
__ High blood pressure or take medicine to control blood pressure?
__ Angina, heart surgery or blood vessel surgery?
__ Sinus surgery?
__ Ear disease or surgery, hearing loss or problem with balance?
__ Recurrent ear problems?
__ Ulcers or ulcer surgery?
__ A colostomy or ileostomy?
__ Sickle cell anemia?
__ Congenital spherocystosis?
__ Frequent or severe attacks of hay fever or allergy?
__ Frequent colds, sinusitis or bronchitis?
__ Any form of lung disease?
__ Pneumothorax (collapsed lung)?
__ Other chest disease or chest surgery?
__ Epilepsy, seizures, convulsions or take medications to prevent them?
__ Recurring complicated migraine headaches?
I hereby give my authorization and consent to receive Hyperbaric Oxygen Therapy:
(Witness signature) (Patient signature)
(Doctor Signature) (Date)
I hereby grant permission to Sacramento Naturopathic Medical Center to take medical photographs of my __________________________________________________________________________________ and hereby authorize the publishing or reproduction of such photographs for correspondence with other health providers that I am seeking treatment and opinion with, as well as for teaching purposes. I also understand that I will not be identified by name and my anonymity will be preserved in any presentation or publication.
(Witness signature) (Date)
(Patient signature) (Date)