New Patient Form Step 1 of 7 14% Name* First Last Date* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Birth Date* Home Phone*Work PhoneCell PhoneEmail* StatusMinorSingleMarriedDivorcedSeparatesParent or Legal Guardian's NameSpouse's NameHome PhoneCell PhoneWork PhoneEmergency Contact*Emergency Contact Phone*What is your primary reason for coming to Hyperbaric Oxygen Therapy of Western NY?*Who may we thank for referring you?* Patient Medical HistoryAre you under medical treatment?* Yes No Do you exercise regularly?* Yes No How often?Do you use tobacco?* Yes No Have you been hospitalized for any surgical operation or serious illness within the past 5 years? Yes No Please explainDo you use alcohol?* Yes No How often?Are you pregnant or think you may be pregnant?* Yes No How many weeks?Date of last menstrual period?Are you taking any medications?* Yes No Medication AllergiesMedical History ListDo you have or have you had any of the following Acute Respiratory Illness AIDS or HIV Infection Anemia Angina Anxiety Arthritis Back Pain Cancer Chemical Sensitivity Chest Pains Chronic Bronchitis Chronic Fatigue (CFS) Claustrophobia Diabetes, Insulin Dependent Emphysema Fainting / Seizures Fever Related Seizures Fibromyalgia Frequent Ear Infection Frequently Tired Glaucoma Hay Fever / Allergies Hepatitis/Jaundice Heart Attack Heart Disease Heart Murmor Heart Problems Herpes High Blood Pressure Infections, Frequent Kidney Disease Leukemia Liver Disease Low Blood Pressure Lung Disease Lung Infection, frequent Malignant Disease Mitral Valve Prolapse Neurological Disease Recent Weight Loss Respiratory Problems Rheumatic Fever Ringing in the Ears Rosacea Seizure Disorders Stomach Problems /Ulcers Stroke Swollen Ankles Thyroid Problems Tuberculosis Do you have or have you had any of the followingRadiation Therapy* Yes No When?Ear problems?* Yes No Ear problems when you fly?* Yes No Ear problems going up & down in an elevator?* Yes No Do you have back problems?* Yes No OtherPatient CommentsSignatureI have accurately answered the questions above. I authorize the release of any medical information from my chart to any physician(s) who may be involved in my medical treatment. I understand it is my responsibility to update this information as needed, including changes in medical conditions / diagnoses, medications, and personal and physician contact information. I agree to be responsible for payment for all services rendered on my or my dependents behalf.Signature* Mild Hyperbaric Therapy Consent FormThe technology known as mild Hyperbaric Therapy (mHBT) 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. OTIC BAROTRAUMA: Is a condition of injury to the eardrum and is extremely unlikely to occur in the mild 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. When the chamber reaches full pressure and again when the chamber is completely deflated there should be no additional pressure in the ears. IF YOU ARE UNABLE TO EQUALIZE EAR PRESSURE AND EXPERIENCE PAIN IN ONE OR BOTH EARS, IT IS CRITICAL YOU COMMUNICATE ANY DISCOMFORT IMMEDIATELY TO THE STAFF. This will give us the opportunity to make adjustments 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 you consult your physician to evaluate and alleviate the situation before attempting another visit. EAR, SINUS or THROAT CONGESTION, HEAD COLD, VIRUS, PRIOR EAR TRAUMA: 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 YOU COMMUNICATE ANY DISCOMFORT IMMEDIATELY TO THE STAFF so we can assist you or terminate your visit. We recommend you consult your physician in order to alleviate the underlying condition before attempting another visit. PULMONARY HYPEREXPANSION: This condition is very rare under mild hyperbaric treatments. However, to be overly cautious, HOLDING YOUR BREATH DURING DECOMPRESSION MUST BE AVOIDED as it could lead to expansion of the air in your lungs and damage to the lung tissues. In the highly unlikely event of an unexpected rapid decompression, it is critical that you exhale immediately. MEDICATIONS: mild 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: MILD HYPERBARIC THERAPY IS NOT ALLOWED DURING THE FIRST TRIMESTER. After this time it may be beneficial to both mother and child. SEIZURES: mild Hyperbaric Therapy is not associated with causing or inducing seizures. To be cautious, we have established a seizure protocol that involves reaching full pressure (4.2psi) and spending full treatment time (standard 1 hour) in the chamber over a series of staged visits. 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 DIE-OFF: mild 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, stomach ache, constipation, diarrhea, headache, behavioral issues, etc. Although unpleasant, this is a natural process and continuing treatments may be of benefit to more rapidly accomplish a positive result. However, IF SYMPTOMS PERSIST, WE RECOMMEND CONSULTING YOUR PHYSICIAN TO EVALUATE AND ALLEVIATE THE SITUATION BEFORE ATTEMPTING ANOTHER VISIT. PNEUMOTHORAX: mild 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 been “cleared from your doctor” to resume normal activity, once you have provided a written confirmation, you should be able to proceed with mild Hyperbaric Therapy. COMPRESSIVE BRAIN LESIONS – SUBDURAL or INTRACRANIAL HEMATOMA: mild Hyperbaric Therapy is contraindicated for existing compressive brain lesions (subdural hematoma, intracranial 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 been “cleared from your doctor” to resume normal activity, once you have provided a written confirmation, you should be able to proceed with mild Hyperbaric Therapy. DIABETES / INSULIN DEPENDENT: 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. You are required to; A) take a blood sugar reading prior to your treatment (if below 150, you must have a snack prior to treatment) and again after your treatment (if below 150, you must have a snack prior to leaving). B) Take a protein bar and a juice box (or whatever you use if faced with a “drop” in the normal management of your condition) into the chamber. SENSITIVITY TO CHEMICALS (MCS) / ODORS / ALLERGY: Avoid wearing 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. We recommend that you wear a charcoal mask or filter if it is known to assist your condition. 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. I have read and fully understand the above information.Date* Signature* Private LicenseThe undersigned hereby grants a Private License to HBOTWNY to provide mild hyperbaric therapy to the undersigned. The undersigned acknowledges that HBOTWNY and its agents neither diagnose nor prescribe for medical or psychological conditions nor claim to prevent, treat, or cure any condition. Its agents do not provide diagnosis, care, treatment or rehabilitation of individuals, nor does HBOTWNY or its agents apply medical, mental health or human development principles, but rather provides mild hyperbaric therapy technology that may benefit. The undersigned acknowledges giving Informed Consent to the services that will be provided. The undersigned hereby releases HBOTWNY and its agents from all claims and liabilities arising from the use or misuse of hyperbaric therapy, indemnifying and holding HBOTWNY and its agents harmless from all claims and liabilities wherefrom, whatsoever. HBOTWNY and its agents reserve all rights. In the unlikely event that the client has a dispute with HBOTWNY, the client agrees that the dispute shall be settled by arbitration through the Better Business Bureau of Rochester. I have read, fully understand and consent to treatments in the mild hyperbaric chamber. I have also completed the health questionnaire which accompanies this consent form, and I agree to hold HBOTWNY harmless from blame regarding hyperbaric therapy services provided by HBOTWNY. Although mild hyperbaric therapy has been reported to be beneficial for a wide range of conditions, this therapy is not meant as a cure for any condition or disease, and no therapeutic outcomes can be guaranteed. We do not in any way recommend hyperbaric therapy as a substitute for any medical treatments prescribed or suggested by any medical physician. We do not make any guarantees to any results that an individual may experience. We are NOT medical practitioners. We do not accept insurance for our services.Date* Signature* HEALTH INFORMATION AUTHORIZATION FORMName* First Last Date* SPECIFIC AUTHORIZATION • I give permission to HBOTWNY to use my address, phone number and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related information, treatment alternatives, or other health related information. • I give permission to HBOTWNY to leave a phone message on my answering machine or voice mail. • I give HBOTWNY permission to provide hyperbaric therapy in an open room where other patients are also receiving hyperbaric therapy. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the practitioner at any time in private, the practitioner will provide a room for these conversations.Date* Signature* PROMOTION AND DOCUMENTATION AUTHORIZATION FORMTo assist in the promotion and documentation of our services here at the center, we request permission to photograph you and/or your child. This photograph may be used, along with your name and testimonial, in printed form on display in our center, in printed form on display during promotional events around the country, in digital form on educational CDs or on our website.Patient First Last Parent or Legal Guardian First Last I give HBOTWNY permission to use my photograph or my child’s photograph in printed form on display at the center or during promotional events and in digital form on a promotional / educational CD or on our website. Yes No I give HBOTWNY permission to use my name and/or my child’s name in printed form on display at the center or during promotional events and in digital form on a promotional / educational CD or on our website. First names only Both first and last name I give HBOTWNY permission to use all or part of my testimonial in printed form on display at the center or during promotional events and in digital form on a promotional / educational CD or on our website. Yes No By signing this form, you are giving HBOTWNY permission to use and disclose your photograph, name and testimonial in accordance with the directive listed above. You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION, HBOTWNY will not refuse to provide treatment. You have the right to revoke this AUTHORIZATION at any time. Details will be provided upon your request.Date Signature If 24 hours notice is not provided for a cancellation, we reserve the right to fully charge your account for your visit. We try and be reasonable and work with all our clients and understand circumstances change. Thank you for your cooperation Please initial belowSignature This iframe contains the logic required to handle AJAX powered Gravity Forms.