HBOT New Patient Form

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  • Patient Information

    Thank you for selecting our hyperbaric team! We will strive to provide you with the best possible service. To help us meet your needs, please fill out this form completely. If you have any questions or need assistance, please let us know. We are more than happy to help!

    CONTINUE ONLY IF:

    Not currently prescribed or taking the following medications: Bleomycin, Disulfiram, Mafenide Acetate.

    Do not have or suspect having: Hereditary Spherocytosis, Sickle Cell Anemia, COPD.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

Refund policy 

All refunds are subject to an internal processing fee of 10% of remaining value.