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Denver HyperBaric Oxygen
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Hyperbaric Oxygen Therapy Approval Form
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:
Signature
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Client/Parent/Legal Guardian
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--- Physician, Physician Assistant, Chiorpractor Approval X
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