Medical Form

Client Information

Family physician or physician aware of your condition.

A positive response to any of the above conditions means that there is a pre-existing condition that may affect your safety in receiving hyperbaric oxygen therapy. Such a condition does not necessarily disqualify you from receiving therapy when appropriate means are in place. The point of the checklist is to ensure that you are physically able to receive hyperbaric oxygen therapy in a hyperbaric chamber. Should you have any doubts about your present physical condition, you may wish to consult with your physician.

By typing your name in the Signature field below, you declare that the information you have provided about the client or your own medical history is accurate to the best of your knowledge.