*1.Client Name(Required.)

*2.Address of Treatment(Required.)

*3.Date of Birth(Required.)

*4.Phone Number(Required.)

*5.Date of Treatment(Required.)

*6.Health & Safety Screening – Please check ALL that apply(Required.)

I have a pacemaker, pain pump, spinal stimulator, or any implanted electrical device

I have COPD or congestive heart failure

I have had a heart attack or heart surgery in the past 6 months

I am pregnant

I have a history of seizures, claustrophobia, or pneumothorax (collapsed lung)

I have sinus, ear, or respiratory issues today (cold, congestion, infection)

I take or recently stopped taking Bleomycin, Disulfiram, Doxorubicin, Cisplatin, or Sulfamylon

I am diabetic – OR – I am diabetic and have taken appropriate glucose precautions today

I am NOT able to equalize ear pressure (yawn, swallow, chew gum, etc.)

I am under the influence of drugs or alcohol

None of the above

*7.Client Responsibilities(Required.)

I will notify staff if I feel discomfort or pressure in my ears

I will not bring phones, keys, lighters, or scented products into the chamber

I will inform staff of any changes in health, medications, or concerns

I understand that nicotine and caffeine may reduce treatment effectiveness

*8.Consent & Liability Waiver(Required.)

I voluntarily choose to receive mild hyperbaric oxygen therapy (HBOT), understanding that results vary, no cure is guaranteed, and this is not a substitute for medical treatment. I understand HBOT is not FDA-approved for many off-label uses.

I release and hold harmless HyperBearic and its owners, agents, and employees from any claims, damages, or liabilities arising from my participation. I accept full responsibility for my decision to receive HBOT and confirm I meet the physical requirements stated above.