Client Portal Clinic Portal

Hyperbaric Oxygen Safety Screening

Intake Form

Yes   No

Yes   No

Checklist Concerns

High blood pressure or taking blood pressure medication*:
Yes   No
Ear or sinus disease*:
Yes   No
Lung disease, heart disease, older, sicker*:
Yes   No
Asthma*:
Yes   No
Claustrophobia*:
Yes   No
Poor Blood Sugar Control and/or Insulin-Dependent diabetic*:
Yes   No
Cataracts*:
Yes   No
Seizure disorders/epilepsy, or taking anti-seizure meds*:
Yes   No
Uncontrolled high fever*:
Yes   No
Diabetes*:
Yes   No
Congenital Spherocytosis or sickle cell anemia*:
Yes   No
Lung disease, COPD, emphysema, collapsed lung, or fluid in the lungs*:
Yes   No
History of chest surgery*:
Yes   No
Pregnancy*:
Yes   No
Cancer*:
Yes   No
Heart Failure*:
Yes   No
Do you have any implanted medical devices? This includes pacemakers, deep brain stimulation, and all other electronic medical device implants) *:
Yes   No
Have you already had any hyperbaric sessions and if so how many and when was your last session*:
Yes   No

Select Purchase

Safety Screening Report only $99

Many doctors are either not trained or do not feel comfortable signing a hyperbaric prescription. This report should help your doctor with this process. We recommend that you take this report to your doctor/healthcare provider and it includes a physician statement on the last page of the report that your doctor can sign off on. If your doctor would like you to speak to one of our O2 providers about yuor risk assessment report, there will be no extra charge for this service - Safety is our number 1 priority.

I would like to add O2 Provider support:

A Professional Assessment (includes safety screening report) $199

A licensed, hyperbaric-trained, healthcare provider will give you and/or your doctor their professional assessment (as to your level of fitness for being inside a hyperbaric chamber). This assessment is based on your online intake form and the answers that you have submitted. Note, you may receive a phone call from the O2 Providers before he/she gives their assessment.

A Signed Physician Statement (includes safety screening report) $349

For those that require specific hyperbaric consultations, a licensed, hyperbaric-trained, physician will consult with you to review with you your hyperbaric safety screening report, answer my questions that you have, and sign the physician statement on the last page of safety screening report. In addition, you will receive full access physician support while you are undergoing hyperbaric therapy for up to 3 months.

Consent Form

Payment Detail

Description Subtotal Discount Total
Service Cost $99.00 $0.00 $99.00

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