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303-641-8149

Heal Yourself with Oxygen

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Name

Birthday

Phone

Email

Reason for Hyperbaric Therpy/Medical Condition

Inner ear Problems

Seizures

High Blood Pressure

Chronic Infections

Sinus Issues

Difficulty Clearing Ears

Lyme Disease

Acute Cold (Congestion)

Heart Disease

Stroke

Please list any medications that you are currently taking or have taken within the last 2 weeks:

Please list any known allergies:

Please list any recent surgeries:

Please list any other medical information that you feel is important for the doctor to know:

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Client/Parent/Legal Guardian

--- Physician, Physician Assistant, Chiorpractor Approval X

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303-641-8149