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Medical Waiver

MEDICAL WAIVER

Consent for electronic signature – The parties herein agree to electronic signatures to execute this agreement online with either written or drawn signatures.

I, , residing at hereby authorize Hyperbaric Health (HH) and its staff to treat me with hyperbaric oxygen therapy as an elective treatment or as prescribed by a physician in a monoplace hyperbaric chamber. The nature and purpose of hyperbaric medicine have been explained to me, and I hereby acknowledge that I understand the nature and purpose of these treatments.

DISCLOSURES

Additionally, I acknowledge the possible risks and side effects of hyperbaric oxygen therapy, including but not limited to those listed below. I have been given the opportunity to ask questions and have my questions answered. I understand that my appointments are scheduled and planned in advance by HH and fees are non-refundable but transferable to any party that obtains medical clearance through HH.

Barotrauma or pain in the ears or sinuses. I may experience pain in the ears or sinuses. I also understand that if I am not able to equalize my ears or sinuses, pressurization will be slowed or halted, and suitable remedies will be applied.
Cerebral Air Embolism and Pneumothorax. Whenever there is a rapid change in the ambient pressure, there is a possibility of rupture of the lungs with the escape of air into the arteries or into the chest cavities outside the lungs. This only occurs if the normal passage of air out of the lungs is blocked during recompression. Only slow recompressions are used in hyperbaric oxygen therapy to obviate this possibility

Oxygen toxicity The risk of oxygen toxicity and seizures has been explained to me and will be minimized by never exposing me to greater pressure or longer times than are known to be safe for the body and its organs—the risk of fire.

Fire risk With the use of oxygen in any form, there is always a risk of fire, but strict precautions have been taken to prevent this by providing me with 100% cotton scrubs. I further understand that nothing is allowed in the chamber (including all electronics), and all applicable codes have been complied with.

The risk of worsening near-sightedness. (Myopia). It is possible I may experience a decrease in my ability to see things far away. I understand that this is usually temporary with the majority of patients.

I understand that it is not advisable to get a new prescription for my glasses until at least eight weeks have passed after hyperbaric therapy. Temporary improvement in far-sightedness. (Presbyopia) It is possible that I may experience an improvement in my ability to see things close or to read without reading glasses. I understand that this could be temporary and that in the majority of patients, vision returns to its pre-treatment level about six weeks after the cessation of therapy. I have been cautioned not to be fitted for new eyewear prescriptions for eight weeks after the end of my treatments.

Maturing or Ripening of Cataracts. In individuals with cataracts, it has occasionally been demonstrated that there may be a maturing or ripening of the cataracts. Serous Otitis. Fluid in the ears sometimes accumulates as a result of breathing high concentrations of oxygen. This disappears after hyperbaric treatment ceases and often can be eased with decongestants. I am aware that the practice of medicine and surgery is not an exact science, and I have been made no promises or guarantees as to the results of Hyperbaric Oxygen Therapy. I have been informed by the staff of Hyperbaric Health (HH) that smoking cigarettes, pipes, cigars, or any other form of tobacco and chewing tobacco products will result in the ingestion of chemicals into the body, which may affect the efficacy of success of hyperbaric treatment.

I have been specifically told NOT to smoke for two hours before treatments.

CLEANING FEE - I hereby authorize Hyperbaric Health (HH) to additionally charge me up to $250.00 USD for any additional cleaning outside of normal use.

PHOTO RELEASE

Yes

I hereby authorize Hyperbaric Health (HH) or its employees to take medical photographs for the purpose of teaching or publication. I also understand that I will not be identified by name and that my anonymity will be preserved in any presentation or publication. I consent to the release of information and /or disclosure of any part of my medical record by any physician, hospital, accreditation, or regulatory organization responsible for monitoring or evaluating health facilities as well as any other facility of which I have been a client. I have read and agree with the information above. I have also read and understand the Patient Safety Requirements and the products that are not allowed into the chamber at any time. I agree and understand that Hyperbaric Health (HH) has been satisfactorily explained to me. I hereby understand that I am entering into hyperbaric treatment at my own risk. I hereby give my authorization and consent to the performance of hyperbaric oxygen therapy by Hyperbaric Health (HH).

I fully understand and agree that neither the operator(s), technicians, managers, owners, safety personnel or medical staff at Hyperbaric Health, LLC. may be held liable or responsible in any fashion for any injury, death or damages to me or my family, heirs, or assigns that may occur as a result of participation in hyperbaric treatment or as a result of active or passive negligence of any of the released parties named in this document.

In exchange for my being allowed to participate in this therapy program, I hereby personally assume all risks in conjunction or connection with this therapy program or any harm or injury or damages that may befall me, my heirs or assigns while I am enrolled in this program. I specifically assume all risks associated with my participation in this treatment, and I will not hold the released individuals in this document responsible.

By my signature on this document, I am evidence that I have fully read, contemplated, and understand the contents of this liability release and express assumption of the risk, and release my right to sue. I agree to the terms and conditions of this document in exchange for my participation in this therapy. I further state that I am of lawful age and legally competent to sign this release or that I have acquired the specific written consent of my parent or guardian.

I understand that this document constitutes a contract between myself and the released parties cited.
This liability release may be used as evidence in a court of law if you decide to sue any released party or person. Please read this document carefully. I understand that I will be held responsible to pay all court cost and Hyperbaric Health's legal fees.

This instrument is to release the employees, technicians, medical staff, safety officers and operator(s) of Hyperbaric Health from all liability and responsibility whatsoever for personal injury, property damage, or wrongful death, however caused, including, but not limited to, the negligence, active or passive.

Customer shall indemnify and hold harmless Hyperbaric Health (and its subsidiaries, affiliates, officers, agents, co-branders or other partners, and employees) from any and all claims, damages, liabilities, costs, and expenses (including, but not limited to, reasonable attorneys’ fees and all related costs and expenses) incurred by Hyperbaric Health as a result of any claim, judgment, or adjudication against Hyperbaric Health. Hyperbaric Health does not warrant that services will meet the customer’s expectations or requirements. the entire risk as to the quality and performance is with the customer. except as otherwise specified in this agreement, Hyperbaric Health provides its services “as is” and without warranty of any kind.

CANCELATION POLICY

I understand that there is a 24-hour cancellation policy. If I am not able to make my appointment, I understand it is my responsibility to call and cancel my appointment. If my appointment is not cancelled 24 hours in advance, I understand I will be charged 50% of the amount of my hyperbaric therapy session, as my cancellation fee. I further understand, if I do not call to cancel my appointment, and I do not attend scheduled appointment, I will be charged FULL Price. I cannot attend or schedule another appointment until my cancellation fee has been paid in full.

PHOTO RELEASE
I hereby grant permission to Hyperbaric Health to use photographs and/or videos of me taken at Hyperbaric Health in publications, news releases, online, and in other communications related to the mission of Hyperbaric Health.

HIPPA AUTHORIZATION

This waiver authorizes Hyperbaric Health (HH) to send and/or receive my medical information as noted. In addition our HIPPA Policy and Private Practice Policy is located on our website and is available for download on our

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Signed by Scott Aadal
Signed On: May 21, 2024

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February 14, 2024 3:10 pm EDT

Medical Waiver Uploaded by Scott Aadal - scott@hyperbarichealth.io IP 72.212.175.189