mHBOT Hyperbaric Treatment Forms

Mild Hyperbaric Oxygen Therapy Informed Consent & Liability Waiver

Should you feel any pain or discomfort in your ears, please inform the practitioner immediately.

GENERAL RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS AND INDEMNITY REGARDING CLINICAL TREATMENT AND PERSONAL USE OF HYPERBARIC OXYGEN THERAPY DEVICES

Mild Hyperbaric Oxygen Therapy is considered an alternative treatment for certain conditions. Although it has been reported to be beneficial for a wide range of conditions, it is not meant as a cure for any condition or disease, and no therapeutic outcomes are guaranteed. These conditions include:

• Autism

• Concussion / Traumatic brain injury (TBI)

• Stroke

• Multiple sclerosis

• Chronic fatigue syndrome

• Fibromyalgia

• Chronic viral infections

• Chronic Lyme

• Wound-healing

• Diabetes

• Seizures

• Headaches

Preparing your body to get the maximum benefit from mHBOT treatment is important and you should note that:

• Consumption of alcohol 3 hours prior to mHBOT is strictly forbidden and will result in cancellation of the session with full cost of treatment incurred.

• Consumption of coffee and cigarette smoking prior to treatment may counteract the attempts to deliver oxygen through Hyperbaric Oxygen therapy.

Potential side effects from mHBOT include

Altitude related side effects

For mild hyperbaric sessions between 1.3 and 1.5 ATA, we ask our clinic clients to keep us posted on their travel plans and we don’t treat them the day before air-travel or other altitude related activities. Allow a minimum of a 24-hour gap as standard practice.

For mild hyperbaric sessions between 1.6 and 2.0 ATA, we don’t recommend a session within 72 hours of flying or travelling to elevated altitudes. Any clients treated for decompression sickness or arterial gas embolism may not fly or travel to elevated altitudes for 72 hours after their hyperbaric treatment.

Blood Sugar drop for people with Insulin-Dependent Diabetes

Insulin dependency may result in a blood sugar drop while in the chamber. It is critical that you immediately communicate to the staff if you experience or anticipate an episode - the session will be terminated.

• Prior to a mHBOT session we ask you to take your blood sugar reading, if it is less than 8.3mmol/L, you must snack prior to session.

• After your mHBOT session we ask you to take your blood sugar reading again and if it is less than 8.3mmol/L you must snack prior to leaving.

Otic Barotrauma

This is a condition of injury to the eardrum and is unlikely to occur in mHBOT. However, severe ear discomfort can be caused if you cannot equalise the pressure in your ears. As the chamber is pressurised, you must equalise the pressure in your ears to acclimatise the pressure changes.

• The most effective way to do this is to hold your nose, close your mouth, and blow. You can also try “popping your ears” by yawning or swallowing. Repeat this throughout the treatment each time you feel pressure build up in your ears.

• If your ears do not acclimate normally, you will experience discomfort in your ear canals. In this case it is important to immediately communicate any discomfort to the technician. They will adjust the pressure to alleviate your discomfort.

• In the unlikely case we are unable to equalise the pressure in your ears, the session will be discontinued and a visit to your physician must be completed prior to another session.

The following are contra-indications for mHBOT. If you are affected by any of these, you need to alert our technician prior to your treatment:

• Confirm that I have read, understood, and agree with the information presented in this consent form, and have had ample opportunities to raise concerns or ask questions.

• Am satisfied that the protocols, and procedures for mHBOT have been explained to me by the mHBOT Technician.

• Have been provided with orientation to mHBOT, which has included indications, contraindications, risks and side-effects, benefits, safety, equalisation techniques, and a chamber and facility overview.

• Will advise the mHBOT Technician of any changes or new conditions about my health and wellbeing that they may need to be aware of prior to any future treatment.

• Accept that the clinic may decline to provide further mHBOT to me, at any time in the future, for any reason that they deem appropriate, if they explain that to me

• Authorise trained staff to render supportive care that their professional judgement may dictate, during the above treatment.

• Consent to collection and retention of relevant information about my health, for the purpose of making sure that I receive appropriate care and treatment.

• Waive and release BioTrace, including all personnel, owners and management, of any and all liability for loss, damage, expense or injury that I may suffer while undertaking Hyperbaric Oxygen therapy (HBOT) treatment in their clinic and/or during my use of any HBOT devices that I may now or in the future rent or purchase from them.

• Acknowledge I have been informed of all potential harm and injury that may possibly result from my usage of HBOT. I understand some conditions may be contra-indications when using HBOT. I will not hold my breath whilst inside the chamber. I will not attend a hyperbaric session under the influence of alcohol or recreational drugs. I am aware that the practice of any medicine is not an exact science and that I have been made no guarantees as to the results of hyperbaric oxygen therapy.

• Acknowledge that I have been advised by BioTrace to seek medical advice if I know or suspect that my physical condition is, or may be, incompatible with the use of HBOT.

I accept that I have informed consent

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