Patient Intake – Hyperbaric PHP

Welcome to Hyperbaric PHP! We’re thrilled to have you join us on your wellness journey. To personalize your hyperbaric therapy experience and ensure the best possible care, please take a few moments to carefully review, fill out, and sign this form. The information you provide will help us tailor your treatment plan and optimize your experience at Hyperbaric PHP.

Hyperbaric PHP Patient Intake Form

Newsletter

Please continue if:

You are not currently prescribed or taking any of the following medications: Bleomycin, Disulfiram, Mafernide Acetate

You do not have a history of, or suspect you may have, any of the following conditions: Hereditary Sperocytosis, Sickle Cell Anemia, COPD

What is your primary reason for visiting Hyperbaric PHP?

How did you find us?

Referred By

1. Patient Information

First Name

Middle Name

Last Name

Date of Birth (MM/DD/YYYY)

Marital Status

Phone Number

2. Parent/Legal Guardian Information

Complete this section only if you are signing this form as the legal representative of a minor.

Relationship to Patient

First Name

Last Name

Phone Number

3. Emergency Contact Information

If the emergency contact is not the same as the parent/guardian listed above, please complete this section

First Name

Last Name

Phone Number

4. Physician Information

Please provide your primary physician information.

Are you currently under doctor’s care?

First Name

Last Name

Phone

Website

5. Patient Medical Screening

Please provide us as much infromation as possible.

Are you currently under medical treatment?

Do you use tabacco or vape products?

Are you taking any medications?

Do you use alcohol?

List of medications

Please describe how often you excersie.

How often do you use alcohol?

List any medications you are allergic to:

Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? If yes, please describe below.

Are you currently pregnant?

If yes, how many weeks?

If no: When was your Last Menstrual Period (LMP)?

Please select if you had any of the following conditions.

Conditions

Acute Respiratory Illness

AIDS or HIV Infection

Anemia

Angina

Anxiety

Arthritis

Asthma

Back Pain

Cancer

Chemical Sensitivity

Chest Pains

Chronic Bronchitis

Chronic Fatigue (CFS)

Claustrophobia

Diabetes – Insulin Dependent

Emphysema

Fainting / Seizures

Conditions

Fever Related Seizures

Fibromyalgia

Frequent Ear Infections

Frequently Tired

Glaucoma

Hay Fever/Allergies

Hepatitis/Jaundice

Heart Attack

Heart Disease

Heart Murmur

Heart Problems

High Blood Pressure

Infections, Frequent

Kidney Disease

Leukemia

Liver Disease

Low Blood Pressure

Conditions

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

Have you ever been diagnosed with the following?

Pneumothorax (Collapsed Lung)

Pleural effusion (Fluid around the Lungs)

Chest Tube Placement

If yes, diagnosed date.

Have you ever had any ear problems?

Do you have any problems with your ears when you fly?

Do you have any problems going up and down in an elevator?

Do you have any back problems?

Additional Information

6. Covid-19 Information

Have you ever been diagnosed with COVID-19?

If yes, when was your most recent diagnosis?

Are you currently experiencing any long-term symptoms of COVID-19 (Long COVID)?

If you selected yes for Long COVID, please check any symptoms that apply:

Fatigue

Difficulty breathing or shortness of breath

Cough

Chest pain or tightness

Changes in taste or smell

Difficulty thinking or concentrating (brain fog)

Sleep problems

Headache

Joint or muscle pain

Other (please specify in the comments box).

Patient Medical Screening Consent

Please provide your constent for the following:

I have answered the medical screening questions truthfully and accurately.

I authorize the release of my medical information from this practice to any healthcare provider involved in my treatment.

I understand that I am responsible for keeping my medical information up-to-date, including changes in diagnoses, medications, contact details (mine and my doctor’s), and insurance information.

I agree to be financially responsible for all services provided to me or my dependents.

Informed Consent

Hyperbaric PHP offers mild hyperbaric therapy treatments. While we believe this therapy may be beneficial for a variety of conditions, it’s important to understand:

We are not a substitute for medical care. Hyperbaric therapy is not a guaranteed cure and should not replace treatments prescribed by your doctor.

Individual results may vary. The effectiveness of hyperbaric therapy can differ from person to person.

We are not medical professionals and do not accept insurance.

Disclaimer: We recommend consulting with your doctor to determine if Hyperbaric therapy is right for you.

Please provide your consent for the following:

I have read and understand the information provided about mild Hyperbaric therapy at Hyperbaric PHP.

I agree to receive mild Hyperbaric therapy treatments at Hyperbaric PHP.

I agree to release Hyperbaric PHP and its staff from any claims or liabilities arising from the use of mild Hyperbaric therapy services provided by Hyperbaric PHP.

In the unlikely event of a disagreement, you agree to settle it through arbitration with the Better Business Bureau of Metropolitan Atlanta.

I agree to be financially responsible for all services provided to me or my dependents.

Communication Preferences

We’d love to keep you informed about your health and appointments at Hyperbaric PHP. Please uncheck any boxes below if you don’t wish to receive these communications.

Please provide your consent for the following:

I authorize Hyperbaric PHP to contact me about appointment reminders & missed appointment notifications (via phone call, text message, or email).

I authorize Hyperbaric PHP to leave a message on my voicemail or answering machine.

Share your story

We’d love to showcase the positive impact we have on our clients! With your permission, we may use photos, videos, and written testimonials you provide to share on our website, in our center, or at events. These stories can inspire others on their health journeys. Please uncheck if you do not wish to share your story.

Please provide your consent for the following:

I consent to the use of photos and/or videos of me and/or my child.

I consent to the use of all or part of my written testimonial, including my name and/or my child’s name.

By signing below, I acknowledge that I have read and understand the information provided on this form, including the potential benefits and risks of Hyperbaric Oxygen Therapy.