Hyperbaric Therapy Consent Form

CONTINUE ONLY IF:

• You are not currently prescribed or taking these medications

o Bleomycin, Disulfiram, Mafenide Acetate

• You do not have or suspect having

o Hereditary Spherocytosis, Sickle Cell Anemia, COPD

The technology known as Hyperbaric Oxygen Therapy has been reported to have beneficial effects for a wide range of conditions, without negative side effects. Nevertheless, as with many treatments, there are areas of concern of which you should be aware.

It is important that you take a few minutes to read the following information:

• OCTIC BAROTRAUMA: This is a condition of injury to the eardrum and is extremely unlikely to occur in the hyperbaric chamber. However, severe ear discomfort can be caused if you cannot equalize the pressure in your ears. As the chamber is pressurized and depressurized, you must be able to equalize the pressure in your ears to acclimate to the pressure changes. You will most likely experience “popping” in your ears. This is normal. You can assist the equalization process by yawning, chewing, swallowing, working your jaw side to side and up and down, turning the head side to side and ear to shoulder. Sitting upright in the chamber during pressurization and depressurization will generally also make the equalization process more comfortable. In general, doing whatever assists you being comfortable when taking off and landing in a plane may be most effective for you. Continue to do this as needed for the duration of pressurization and depressurization. There should be no additional pressure in the ears when the chamber reaches full pressure and again when the chamber is completely deflated.

• EAR, SINUS AND/OR THROAT CONGESTION, HEAD COLDS, VIRUS OR PRIOR TRAUMA TO THE EARS: You may consider rescheduling your visit in the chamber if you are suffering from any of these conditions. Discomfort from these conditions is less frequent, but may occur.

IF YOU ARE UNABLE TO EQUALIZE EAR PRESSURE AND EXPERIENCE PAIN IN ONE OR BOTH EARS, IT IS CRITICAL THAT YOU COMMUNICATE ANY DISCOMFORT IMMEDIATE TO THE STAFF.

This will give us the opportunity to adjust in the pressurization or depressurization process to eliminate discomfort. If you are unable to equalize the pressure in your ears, the visit will be immediately terminated. If this happens or if pain persists beyond the visit, we recommend that you consult your physician to evaluate and alleviate the situation before attempting another visit.

PULMONARY HYPEREXPANSION: This condition is very rare under hyperbaric treatments. However, to be overly cautious, HOLDING YOUR BREATH DURING DECOMPRESSION MUST BE AVOIDED as it could lead to an expansion of the air in your lungs and cause damage to the lung tissues. In the highly unlikely event of an unexpected rapid decompression, it is critical that you exhale immediately.

MEDICATIONS: Hyperbaric Therapy may enhance the effectiveness or increase the metabolism (decrease the effectiveness) of any medication you are taking. IT IS RECOMMENDED THAT YOU HAVE THE DOSAGE AND FREQUENCY OF ALL MEDICATIONS MONITORED AND ADJUSTED REGULARLY BY YOUR PHYSICIAN.

PREGNANCY: HYPERBARIC THERAPY IS NOT ALLOWED DURING THE FIRST TRIMESTER. After this time, it may be beneficial to both mother and child.

SEIZURES: Hyperbaric Therapy is not associated with causing or inducing seizures, but IF ANYONE GETTING IN THE CHAMBER IS SEIZURE PRONE, THE STAFF MUST BE MADE AWARE PRIOR TO THE FIRST VISIT. If a seizure is experienced in our clinic, unless otherwise instructed (and a waiver is signed), our procedure is to call 911, remove the patient from the chamber and make the individual as comfortable as possible.

DETOXIFYING OR CELL DIEOFF: Hyperbaric Therapy may assist the body to naturally detoxify and balance digestive flora. AN INDIVIDUAL MAY EXPERIENCE SOME DISCOMFORT FROM THIS PROCESS IN AS LITTLE AS 1 TO 36 HOURS AFTER TREATMENT. Symptoms may include flu-like symptoms, loss of appetite, stomachache, constipation, diarrhea, headache, behavioral issues, etc. Although unpleasant, this is a natural process and continuing treatments may be of benefit to accomplish a positive result more rapidly. However, IF SYMPTOMS PERSIST, WE RECOMMEND CONSULTING YOUR PHYSICIAN TO EVALUATE AND ALLEVIATE THE SITUATION BEFORE ATTEMTPING ANOTHER VISIT.

PNEUMOTHORAX: Hyperbaric Therapy is contraindicated for an existing pneumothorax (collapsed lung). IF YOU HAVE A PNEUMOTHORAX OR SUSPECT THAT A PNEUMOTHORAX IS AN ISSUE, YOU WILL NOT BE ALLOWED IN THE CHAMBER UNTIL YOU/WE RECEIVE A DOCTOR’S CLEARANCE. If you have experienced a pneumothorax in the past and have already been “cleared by your doctor” to resume normal activity, once you have provided a written confirmation, you should be able to proceed with Hyperbaric Therapy.

COMPRESSIVE BRAIN LESIONS – SUBDURAL HEMATOMA, INTERCRANIAL HEMATOMA: Hyperbaric Therapy is contraindicated for existing compressive brain lesions (subdural hematoma, intercranial hematoma). IF YOU HAVE COMPRESSIVE BRAIN LESIONS OR SUSPECT THAT COMPRESSIVE BRAIN LESIONS ARE AN ISSUE, YOU WILL NOT BE ALLOWED IN THE CHAMBER UNTIL YOU/WE RECEIVE A DOCTOR’S CLEARANCE. If you have experienced compressive brain lesions in the past and have already been “cleared by your doctor” to resume normal activity, once you have provided a written confirmation, you should be able to proceed with Hyperbaric Therapy.

DIABETES/INSULIN DEPENDANT: Insulin dependency may result in a drop in blood sugar while in the chamber. IT IS CRITICAL THAT YOU IMMEDIATELY COMMUNICATE TO THE STAFF IF YOU EXPERIENCE OR ANTICIPATE AN EPISODE. YOUR TREATMENT WILL BE TERMINATED.

SENSITIVITY TO CHEMICALS (MCS) / ODORS / ALLERGY: Avoid wearing heavy colognes as the smells may linger in the chamber and have an adverse effect on another patient. IF YOU EXPERIENCE ADVERSE SENSITIVITY OR HAVE ALLERGIES THAT MAY BECOME AGGRAVATED WHILE IN THE CHAMBER, LET THE STAFF KNOW PRIOR TO YOUR VISIT OR AS SOON AS POSSIBLE WHEN IN THE CHAMBER SO MEASURES CAN BE TAKEN TO ASSURE YOUR COMFORT OR IF YOUR VISIT NEEDS TO BE TERMINATED. If these sensitivities persist and you cannot exist comfortably in the chamber, you will need to consult your physician in order to alleviate the underlying condition before attempting another visit.