Microsoft word - new patient paperwork.doc

Have you undergone Hyperbaric Treatment Before? If yes , explain: Is there any chance of you being pregnant? Mechanical damage of the ears or sinuses: Chronic or Current Ear, Nose, or Throat infection: Do you have, or have you ever had any of the following? Do you take any of the following drugs? V: 949.680.1880 · F: 949.680.1919 · · Personal Items: For your convenience lockers are provided for your personal items. South Coast Hyperbaric Center is not responsible for lost or misplaced items. Missed Appointments: We value you as a client and will go the extra mile to accommodate your scheduling needs to the best of our ability. Please extend us the same courtesy by letting us know if you will not be able to make a scheduled appointment. Repeat offenders may incur a charge of $50.00 at our discretion. If you have nasal congestion, sinus problem or head cold, on the day of the treatment, it is not recommended you receive hbot that day. Heavy cardiovascular exercise is not recommended one hour prior to your treatment as well as four hour after your treatment. 100% cotton clothing is recommended for hbot. Electronic devices, all metal, jewelry and watches are not permitted in If you have any questions regarding your medications consult the If you have had any new dental work especially fillings, you must wait 48 hours before going in the chamber to preserve the integrity of the fillings. Do not smoke at least four hour prior to your treatment. Do not fly or drive to a higher altitude within 12 hours of completing Insurance: Medicare or Private Insurance does not generally cover hbot. Any arrangement between insurance carrier and myself is my responsibility. If your indication is covered by insurance we will prepare any necessary reports and or forms to assist you in making your collection. I understand that if I suspend or terminate my care and treatment, ay fees for services rendered to me will be immediately due and payable. Initials: V: 949.680.1880 · F: 949.680.1919 · · Informed consent for hyperbaric oxygen treatment I hereby authorize South Coast Hyperbaric Center to treat me in the hyperbaric chamber and do all that is required as part of that therapy. If any unforeseen conditions arise during the course of this treatment, I do hereby authorize and request the physician and his/her assistants to perform such additional procedures and/or to render such treatment as he may in his/her professional judgement deem necessary. The physician or a staff member had explained t me the general methods of the procedure, and explained to me the special risks, contraindications, and consequences associated with hyperbaric oxygen therapy. These include, but are not limited to: The alternatives to this therapy have been explained, and I have been informed that I can refuse treatment. I understand and acknowledge that no guarantee or assurance has been made to me regarding the results or risks, and I assume such risk as explained to me. I, also, consent to and authorize the administration of medication to me during the administration of hbot, and I assume all risks in connection with the use of such medication. I certify that I have read, or have had read to me, this consent and fully understand its contents. Patient Signature: V: 949.680.1880 · F: 949.680.1919 · · If you are receiving Hyperbaric Treatments it is important to understand how to clear your ears. While inside the chamber you must help your ears to clear by equalizing the pressure you feel. You can accomplish this in three manners: Valsalva (pinch your nose shut & attempt to gently blow through nose) Wiggle jaw repeatedly or chew gum (if treated in a sit-up chamber) All of these techniques must be repeated every time you feel pressure building in your ears. If your ear does not clear using these techniques you must knock on the chamber, so we can stop for a moment and let your ears adjust to the pressure. If you do not, you will have pain & sore ears for several days. Hyperbaric treatments should be painless. Your ears may do some funny things while you are undergoing treatments in the hyperbaric chamber. You may experience some or all of the following: Popping or crackling in the ear (especially when you yawn) You may experience some of these symptoms at any point during or following your treatment. It is important to understand that it is OK if you experience some or all of these symptoms. If you experience any of the following please inform your Hyperbaric Technician prior to your next treatment. We will examine your ears to rule out any problems, and administer ear drops if needed. May feel as though you have water in your ear One or both of your ears may be plugged Please work with us to ensure that you have a comfortable experience in the chamber & are able to receive all the wonderful benefits from receiving hyperbaric oxygen therapy! V: 949.680.1880 · F: 949.680.1919 · ·



Economic Evaluation of Treatment Strategies for Benign Prostatic Hyperplasia—Is Medical Therapy More Costly in the Long Run? Christopher S. Saigal,* Mehran Movassaghi, Jennifer Pace, Geoffrey Joyce and the Urologic Diseases in America Project From the Department of Urology, University of California-Los Angeles Medical Center, Los Angeles, California Purpose: Although medical therapy fo


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