Hyperbaric Oxygen Therapy Consent

As the patient, you have the right to be informed about your condition and recommended medical procedures so you can make an informed decision whether or not to undergo any procedure after knowing the risks and hazards involved in such procedures. By signing this consent, you and the patient are voluntarily consenting to receive hyperbaric oxygen therapy treatments provided by Restorative Oxygen Care, LLC. Patient understands that this consent will remain from the date signed to the date of discharge. A new consent will be obtained from the patient if the patient returns for more treatments after being discharged. Patient understands that Patient has the right o refuse consent to any proposed treatment at any time. If a patient unable to sign because of incapacity or age, then a legal guardian is authorized to sign on the patient's behalf, receiving treatment under this consent.

Medical Condition: Patient acknowledges that the Physician or Nurse Practitioner has explained the patient's general condition to why hyperbaric oxygen therapy is appropriate treatment for the patient. The patient also acknowledges that the patient's hyperbaric oxygen therapy will consist of being in an enclosed hyperbaric chamber. Patient will breathe 100% oxygen, and that the pressure inside the chamber can reach 2-3 times the atmospheric pressure the patient is accustomed to. Patient acknowledges that the physician or nurse practitioner has explained all the risks and benefits to the patient. Patient acknowledges that patient has had ample time to ask questions about the hyperbaric oxygen treatments and the physician or nurse practitioner has answered all hyperbaric oxygen treatment questions.

Refusal of Hyperbaric Oxygen Treatments: Patient acknowledges that they may refuse to receive hyperbaric oxygen treatments at any time.

Healing Probability: Patient acknowledges that the physician or nurse practitioner has explained that by completing the hyperbaric oxygen treatments, patient is more likely to have positive results; however, that any treatment carries a risk of unsuccessful results, complication and injuries from both known and unforeseen causes. Patient also acknowledges and agrees that no representation made to the patient by the physician or nurse practitioner constitutes a warranty or guarantee of successful results or cure from completing hyperbaric oxygen treatments.

Side Effects of Hyperbaric Oxygen Treatments: Patient acknowledges that the physician or nurse practitioner has explained the side effects of hyperbaric oxygen treatments , but not limited to the following: temporary or permanent vision problems, ringing in the ears, muscle twitching, irritation or permanent changes to the lungs, nausea and seizures. Patient acknowledges that the physician or nurse practitioner has explained the increased pressure related risk of injury to the ears, sinuses, and lungs, if the patient cannot adequately equalize pressure. The 100% oxygen environment under pressure increases the risk of fire which may cause serious injury or death.

Medical Conditions: Patient acknowledges that the physician or nurse practitioner has explained that there are a series of medical conditions which may interfere in receiving hyperbaric oxygen treatments. Patient must inform physician or nurse practitioner of any physical illness including, but not limited to any of the following conditions; untreated cancer, untreated collapsed lung, chronic sinusitis, upper respiratory infection, chronic obstructive lung disease (also known as COPD, emphysema, asthma, bronchitis, etc.), heart disease with congestive failure, current high fever or viral illness, history of chest or ear surgery and pregnancy.

Diabetics: Patient acknowledges that the 100% oxygen environment under pressure causes diabetic patients' blood sugar to drop during treatments. Patient acknowledges that if patient does not eat prior to treatment that the risk of having critically low blood sugar during and after treatment can cause serious injury or death.

Pictures/Images/Medical Records: Patient consents to Restorative Oxygen Care employees (physicians, nurse practitioners, chamber operators, nurses, safety director) to take photographs of any wounds while being treated at Restorative Oxygen Care. Patients acknowledge that pictures will be taken to monitor progression of the wounds before and after treatments. All medical information obtained from other physicians, nurse practitioners, and insurance companies for the patient's treatments will be handled, maintained, and retained, in a confidential, secure, and protected manner in accordance with applicable laws, regulations, and Restorative Oxygen Care's privacy and retention policies. The patient further acknowledges and agrees that Restorative Oxygen Care can share images and medical information with referring or other treating physicians or nurse practitioners in a secure and protected manner. Patient understands that Restorative Oxygen Care will retain ownership rights to these images and that the patient may view and/or receive copies of medical records which includes documentation and images. Patient understands that patient expressly waives any and all rights to royalties or other compensation fro these images. Images that identify the patient will not be released outside Restorative Oxygen Care without written authorization from patient or patient's legal guardian.

Financial Responsibility: Patient understands that the patient is responsible for any cost associated with the patient's treatments and medical care not covered by the insurance provider. (Treatments, dressing changes, and other materials needed for care)

Risk vs Benefits: No guarantees can be made by ROC and/or staff that any benefit will occur from hyperbaric oxygen treatments. Our recommendations to patients are based of preponderance of evidence that you may receive benefit from an off-label treatment - which treatment is not represented to be risk free.

Refunds/Missing Treatments/Discharge: For cash payments/off-label treatment(s), there are no refunds for missing treatments. Facility expenses (staff, time slot, etc.) are still incurred if patient does not show up for a treatment. If you are discharged from Restorative Oxygen Care due to missing or "No Call/No Show" treatment appointments, there are no refunds for pre-paid treatment(s).

By signing below, patient acknowledges that patient has read this document or had the document read to the patient and understands the information set forth in it and had the opportunity to ask questions and receive answers to questions about consent document and information set forth in the document. Additionally, by signing below, patient consents to any care, treatment, images, disclosures of medical information and services explained and provided by physicians, nurse practitioners, and employees of Restorative Oxygen Care, LLC.