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1 Phne Address: nd Ave NE Redmnd, WA Client Name Date f Birth Diagnsis Patient s Address CONTACT INFORMATION FORM Hme phne Mbile Phne Wrk Phne address Emergency Cntact Name Emergency Cntact Relatinship t Patient Emergency Cntact Address Emergency cntact phne Hw did yu hear abut us?

2 nd Ave NE, Redmnd WA Phne Fax INFORMED CONSENT FOR HYPERBARIC TREATMENT 1. I, hereby authrize Washingtn Hyperbaric Therapy Center, LLC, r such assistants as he r she may designate, t treat me with hyperbaric xygen therapy fr the diagnsis f. 2. The prcedures and reasn(s) fr it have been explained t me; including the risks and benefits f the prcedure, the availability, and benefits f alternate mdes f treatment, and the pssibility f cmplicatins. I understand that I shall lie n a stretcher r sit in a hyperbaric chamber and breathe xygen at greater than nrmal atmspheric pressure. I understand that each treatment will be fr a prescribed amunt f time and treatment may be terminated at any time. 3. I have als been made aware that pssible risks and side effects f hyperbaric xygenatin include, but are nt limited t: a. Bartrauma r pain in the ears r sinuses l I may experience pain in the ears r sinuses, I als understand that if I am nt able t equalize my ears f sinuses that pressurizatin will be slwed r halted and suitable remedies will be applied. b. Cerebral Air Emblism and Pneumthrax Whenever there is a rapid change in the ambient pressure there is a pssibility f rupture f the lungs with escape f air int the arteries r int the chest cavities utside the lungs. This can nly ccur it the nrmal passage f air ut f the lungs is blcked during decmpressin. Only slw decmpressins are used in hyperbaric xygen treatment t bviate this pssibility. c. Oxygen txicity The risk f xygen txicity has been explained t me and will be minimized by never expsing me t greater pressure r lnger times than are knwn t be safe fr the bdy and its rgans. d. Risk f fire With the use f xygen in any frm there is always a risk f fire, but strict precautins have been taken t prevent this and all applicable cdes have been cmplied with. e. Risk f wrsening f near-sightedness (Mypia)After twenty r mre treatments, especially if I am ver frty, it is pssible I may experience diminutin in my ability t see things far away. I understand that this is usually temprary and that in the majrity f patients, visin returns t its pre-treatment level six weeks after the cessatin f I understand that it is nt advisable t get a new prescriptin fr my glasses until at least eight weeks have passed after hyperbaric f. Maturing f Ripening Cataracts In individuals with cataracts it has ccasinally been demnstrated that there may be a maturing r ripening f the cataract. g. Temprary Imprvement in Far-sightedness (Presbypia)After twenty r mre treatments, especially if I am ver frty, there is a pssibility that I may experience

3 an imprvement in my ability t see things clse by r t read withut reading glasses. I understand that this is temprary and that in the majrity f patients, visin returns t it s pre-treatment level abut six weeks after the cessatin f I have been cautined nt t be fitted fr new eyewear prescriptins fr eight weeks after the end f my treatments. h. Numb fingers A small prtin f patients smetimes ntice a numb feeling in the furth and fifth fingers f the hands after twenty r mre treatments. This shuld nt be a cncern and shuld disappear in abut six weeks fllwing cessatin f i. Serus Otitis Fluid in the ears smetimes accumulates as a result f breathing high cncentratins f xygen. I may ccasinally feel like I have a pillw in my ear. This disappears after hyperbaric treatment ceases and ften can be eased with decngestants. j. Fatique Sme peple may subjectively feel fatique fllwing hyperbaric treatment, but this is nt a cnsistent feeling. 4. I hereby authrize Washingtn Hyperbaric therapy Center LLC. r their emplyees t take medical phtgraphs fr the purpses f teaching r publicatin. I als understand that I will nt be identified by name and that my annymity will be preserved in any presentatin f publicatin. 5. I am aware that the practice f medicine and surgery is nt an exact science and I have been made n prmises r guarantees as t the results f hyperbaric xygen 6. I have been infrmed by the staff f Washingtn Hyperbaric Therapy Center LLC. that smking cigarettes, pipes, cigars, r any ther frm f tbacc, and the chewing f tbacc prducts, will result in the ingestin f chemicals int the bdy which may affect the efficacy and success f hyperbaric treatment. I have been specifically tld nt t smke during the entire duratin f treatment. I hereby agree t urine r bld testing fr the presence f nictine r carbn mnxide in my system. 7. I cnsent t the release f infrmatin and/r disclsure f any part f my medical recrd by any physicians, hspital, accreditatin, versight review r regulatry rganizatin respnsible fr mnitring r evaluatin f health facilities, as well as any ther facility f which I have been a client. My signature belw cnstitutes acknwledgement that I have read and agree t the freging and the physician has satisfactrily explained Hyperbaric Oxygen Therapy t me, and that I have all the infrmatin that I desire. I hereby understand that I am entering int hyperbaric treatment at my wn risk. I hereby give my authrizatin and cnsent t the perfrmance f hyperbaric xygen therapy by Washingtn Hyperbaric Therapy Center LLC. Signature f Patient r Authrized Representative Date Witness t Signature Date

4 nd Ave NE, Redmnd WA Phne Fax Cancellatin Plicy Washingtn Hyperbaric Therapy Center LLC reserves the right t cancel a patient's appintment r therapy at any time. If a patient wishes t cancel an appintment r therapy, a minimum f 24 hurs befre the scheduled time is required. The full price f therapy will be charged if this plicy is nt met. I understand that I must give a minimum f 24 hurs ntice befre the scheduled appintment t cancel my therapy in rder t make up fr the treatment cancelled. Patient/Guardian Signature Date

5 HEALTH HISTORY Patient Name: Gender Male Female Tday s Date Age Birth date Date f Last Physical Reasn fr Visit SYMPTOMS Please check all symptms yu have had in the last year GENERAL GASTROINTESTINAL Allergies Nausea Chills Vmiting Fainting Fever CARDIOVASCULAR Headache Chest pain/angina High Bld Pressure High bld pressure Nervusness Irregular heart beat Numbness Weakness GENITO-URINARY Bld in urine Lack f bladder cntrl RESPIRATORY Persistent cugh Shrtness f breath EYE, EAR, NOSE & THROAT Ear Pain Sinus prblems Stuffy nse Visual flashes r hal MUSCLE/JOINT/BONE Pain, weakness, numbness in: Arms Back Legs CONDITIONS Check cnditins yu currently have/had in the past Anemia Arthritis Asthma Bleeding Disrder Bld Clts Cancer Emphysema/COPD Epilepsy Heart Disease High Bld Pressure Strke