Disclosure and Informed Consent for Hyperbaric Therapy

I request and authorize, or as the Legal Guardian, that I or they, be included as a patient for the use of Hyperbaric Therapy.

I understand that the procedures and risks related to Hyperbaric Therapy to be the following:

1. I will be placed in a hyperbaric Chamber that will be pressurized with compressed air to a pressure of up to three (3) atmospheres absolute, which is the amount of pressured used during treatment. During therapy in the Multiplace Chamber, I will be seated, and may be with other patients present, and will breathe pure oxygen using a plastic hood that covers my entire head.
2. In the Monoplace Chamber I will rest in a reclining position on a gurney that slides into the chamber. In either case, I will be able to communicate with the qualified attendant/and or operator during my entire treatment.
3. I have been advised that while dangers are minimal, it is possible that I may experience discomfort to my ears, sinuses, or teeth due to the change in barometric pressure. If such discomfort occurs, I will notify the attendant, who will stop the treatment until the problem has been resolved. I understand that some individuals who experience discomfort with their ears.
4. I may require a myringotomy. An ear, nose and throat specialist generally performs this as an outpatient procedure. I understand that if this procedure is required, I will miss hyperbaric treatments until the procedure has been done.
5. If I have any lung abnormalities, it is possible that during decompression, I may experience problems due to the trapping of air in some parts of the lungs. This may result in an arterial gas embolism, collapsed lung, or emphysema. While these problems may be serious, my physician is aware of these potential problems and does not believe that any pulmonary abnormalities exist based on the X-Ray submitted on my behalf.
6. I understand that I must eat shortly before coming for treatment, and a source of glucose will be provided and available during treatment if needed. Water, Gatorade and small snacks are always readily accessible, and I understand the importance of staying hydrated before and after each treatment.
7. I understand there are risks involved in any procedure or treatment, and it is not possible to guarantee or give assurance of a successful result.
8. I understand that it is not uncommon for the eyes to undergo minor refraction during an extended series of hyperbaric treatments. I understand that this change occurs more frequently in individuals over the age of 50 than those who are under the age of 50. I understand that these changes are usually temporary, and that after discontinuing treatment the eyes usually return to their previous condition.
9. I understand that the use of certain medication is contraindicated during treatment with hyperbaric oxygen therapy, and I agree to inform the facility personnel of all medication that I am currently taking, or have taken in the last six months.
10. I understand that it is my responsibility to report any change in medical conditions, accidents or change in overall health to the attendant before a treatment.
11. I am satisfied with my understanding of the nature of the procedure or treatment and all additional questions have been answered.