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Hyperbaric Oxygen Therapy (HBOT) Checklist


HBOT has been reported to have beneficial effects for a wide range of conditions without negative side effects. Nevertheless, you should be aware of areas of concern.


Please read the following information carefully before doing any treatments. Note: All fields and questions must be complete and/or answered. (Optional complete, print and fax +1-321-325-2200 (F)

First Name

Last Name

Valid Email Address

Valid Email

Mailing Address

Date of Birth
Month
Day
Year

Privacy (HIPPA Protected). Required to proceed. Date of Birth

Insurance Considered? | Select From Dropdown List.
1. Otic Barotrauma (injury to the eardrum), Ear Pressure
Yes
No

(Patient can be taught to equalize pressure in the ears to reduce pain. If unable to equalize the ear pressure, treatment will be terminated)


2. Colds, Flu, Sinus and/or Throat Congestion, Coughing, Virus Infection, etc.
Yes
No

(Consider rescheduling treatment. Lungs, throat and nose must be clear before treatment. If problems arise during treatment, please communicate with staff to terminate session.)


3. Pneumothorax (collapsed lung), Pneumo-mediastinum (fluid in lungs)
Yes
No

(Medical doctor's written clearance needed)

4. Pneumonia, Emphysema and/or any other air-trapped illness evidenced by an air bronchogram.
Yes
No

(Medical doctor's written clearance needed that lungs are clear before treatment)

5. Drug Abuse or other Intoxications such as Alcohol, Smoking, etc.)
Yes
No

(Medical doctor's written clearance needed)


6. Compressive Brain Lesions such as Subdural Hematoma or Intercranial Hematoma.
Yes
No

(Medical doctor's written clearance needed)

7. Diabetes with tendency toward Hypoglycemia.
Yes
No

(Eat 2 hours before treatment. Take blood sugar level prior to treatment to avoid low blood sugar)


8. Claustrophobia
Yes
No

(Pressure & time will be increased slowly. May require a tender in the chamber)


9. Behavior Disorder 
Yes
No

(Patient may require a tender in the chamber)


10. Pregnancy
Yes
No

Not allowed First Trimester. (For remainder of pregnancy, must have medical doctor’s written clearance)


11. Pulmonary Hyper expansion
Yes
No

Do Not Hold Your Breath during Decompression

(This condition is very rare during treatments in the chamber)


12. Sensitivity to Chemicals (MCS), Odors, Allergy.
Yes
No

(Avoid wearing heavy perfumes or colognes, as smells may linger & have adverse effect on others)

Hyperbaric Therapy may assist the body to naturally detoxify and balance digestive flora. An individual may experience some discomfort from this process after treatment.


Symptoms include: loss of appetite, stomachache, constipation, diarrhea, headache, flu-like symptoms, 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 the symptoms persist, please consult Dr. Hardoon Office to evaluate and alleviate the situation before attempting another visit.


Also, if you answered "YES" to any of the above questions, please consult Dr. Hardoon Office.


Please be advised that if any discomfort occurs while in the hyperbaric chamber, the patient must call for staff to come and terminate the treatment session.


The patient may be advised to consult their own medical physician to evaluate the situation before attempting another visit.


Hold Harmless Acknowledgement for Suntree Hyperbaric Center, LLC


By signing below, I acknowledge that I am voluntarily participating in hyperbaric oxygen therapy and related services provided by Suntree Hyperbaric Center, LLC.


I understand and agree that Suntree Hyperbaric Center, LLC, its physicians, medical technicians, employees, and executive management (collectively referred to as "the Center") shall not be held liable for any injuries, damages, losses, or adverse effects that may occur as a result of my participation in these services.

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Disclaimer

 ​

 Suntree Hyperbaric Center, LLC provides HBOT as a supportive therapy and does not make any claims, promises, or guarantees regarding specific medical outcomes. All information provided by Suntree Hyperbaric Center, LLC is for educational purposes only and should not replace professional medical advice, diagnosis, or treatment.


6525 3RD STREET  SUITE 106 ROCKLEDGE, FL 32955 |

+1-321-334-2000 (O) +1-321-325-2200 (F)



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