Hyperbaric Oxygen therapy Consent Form

We are 100% committed to the health and well-being for everyone. We are doing everything we can to keep potential exposure out of our office.

As part of the local and state guidelines you must answer no to all the following questions each time you enter Pua Manu MedSpa.

Not present a fever over 100 F/ 37 C.
Not presenting cold, cough, difficulty breathing muscle pain, headache,
loss of taste/smell or pink eye in past 5 days.
Not in contact with anyone with these symptoms in the past 5 days.
Not in contact with anyone diagnosed with COVID-19, sick and quarantined, in the past 5 days.
All information above is true. I may be asked again when I arrive for my appointment. 
ALL PATIENTS AND STAFF ARE REQUIRED TO: 

Please follow our local and state regulations and guidelines, including those related to occupancy levels, social distancing and other measures intended to reduce the spread of viruses.
Stay home if you are sick or are exhibiting symptoms of illness such as a fever or persistent cough.
Face mask are required to enter the Spa.
Refrain from shaking hands or other touching rituals.
Wash hands for 60 seconds with soap and warm water prior to treatment or use hand sanitizer.
Refrain from eating or drinking while in the Spa, face mask should not be removed. 
I understand that Pua Manu MedSpa has put in place reasonable safety measures to help reduce the spread of COVID-19.

I understand that I am consenting to an elective treatment/procedure that is not urgent or emergent. I understand that it may put me at increased risk for becoming infected with COVID-19, due to potential community exposure.

PATIENT’S ACCEPTANCE OF RISKS

I consent to accept the risks described above and give my permission to proceed with the treatment/procedure.

I have read this consent or someone has read it to me and want to proceed.

Photos will be taken before, during and after the course of my treatments for medical purposes and to evaluate treatment effectiveness. My photos will be kept confidential in my electronic patient record. If you refuse to take any photos, please understand that we will not be able to perform any treatments on you.

I have provided Pua Manu MedSpa a letter from my Primary Doctor's office stating I have his/her permission to have Hyperbaric Therapy Treatment. 

CHECKLIST FOR ON-GOING HYPERBARIC SESSIONS

Please inform the staff EVERY TIME you enter the hyperbaric chamber if:

• There have been any changes in your health, in your medical condition, or in your medications/supplements

• You experience a cold, flu symptoms, sinus or nasal congestion, or chest congestion.

• There is a possibility you may be pregnant.

• You have skipped a meal prior to HBT treatment.

• You are a diabetic and did not take your insulin prior to treatment

• You have any concerns or anxiety

WHAT IS MY ROLE AND RESPONSIBLILTY TO ENSURE SAFETY?

Your role is quite simple: Arrive 15 minutes prior to your appointment, communicate with our staff each time, and let them know if there are any changes in your health. For example, you may have reported on your first visit that you were not pregnant,
but when you come in for multiple visits it is your responsibility to let us know if there are any changes in your health, and in this example, it would be ‘if you are potentially pregnant’. This is the reason why the checklist for on-going hyperbaric sessions must be answered each time you go into the hyperbaric chamber. This is for your safety and once again it is your responsibility to let us know each time you go in ‘if there are any changes’ in your health.

1. Wear 100% cotton clothes, other materials may cause sparks.

2. No hair sprays, no makeup.

3 No velcro clothes or material.

4. No electronics.

5. All pockets must be emptied prior to entering the chamber/

6. No books or papers, leave your face mask outside the chamber.

7. Step on the floor without your shoes before getting into the chamber, release any static on your body.

 

Also, inform the staff IF THE PRESSURE IS TOO GREAT FOR YOUR EARS. Often, people have trouble adjusting to an increased atmospheric pressure. If your ears hurt, inform the staff immediately and he/she can stop or slow down the rate of pressurization until you are comfortable. DO NOT LET IT GET PAINFUL!

The Airplane Analogy: In an airplane, if your ears are hurting, you cannot tell the pilot to stop climbing or descending. However, in a hyperbaric chamber, if your ears are uncomfortable it is your responsibility to tell the chamber operator to slow down or stop the pressurization process. This will help avoid an unpleasant experience during your hyperbaric session. 

Hyperbaric Oxygen Therapy Consent Form Hyperbaric Oxygen Therapy (HBOT), has been reported to have beneficial effects for a wide range of conditions, without negative side effects that can be harmful to your health. Nevertheless, as with many treatments, there are areas of concern which you should be aware. It is important that you take a few minutes to read the following information. OTIC BAROTRAUMA: Is a condition of injury to the eardrum, and is extremely unlikely to occur in the hyperbaric chamber. However, severe ear discomfort can be caused if you cannot equalize the pressure in your ears. As the chamber is pressurized and depressurized you must be able to equalize the pressure in your ears to acclimate to the pressure changes. You will most likely experience "popping" in your ears. This is normal. You can assist the equalization process by yawning, swallowing, working your jaw side to side and up and down (chewing motion), turning the head side to side and ear to shoulder. Sitting upright in the chamber during pressurization and depressurization will generally also make the equalization process more comfortable. In general, whatever assists you being comfortable when taking off and landing in a plane may be most effective for you. Continue to do this as needed for the duration of pressurization and depressurization. When the chamber reaches full pressure and again when the chamber is completely deflated there should be no additional pressure in the ears.

IF YOU ARE UNABLE TO EQUALIZE EAR PRESSURE AND EXPERIENCE PAIN IN ONE OR BOTH EARS, COMMUNICATE ANY DISCOMFORT IMMEDIATELY TO THE STAFF. This will give us the opportunity to make adjustments in the pressurization or depressurization process to eliminate discomfort. EAR, SINUS AND/OR THROAT CONGESTION, HEAD COLDS, VIRUS OR PRIOR TRAUMA TO THE EARS: You may consider rescheduling your visit in the chamber if you are suffering from any of these conditions. Discomfort from these conditions is less frequent but may occur.

 

MEDICATIONS: Hyperbaric Oxygen Therapy may enhance the effectiveness of any medication you are taking. IT IS RECOMMENDED THAT YOU HAVE THE DOSAGE AND FREQUENCY OF ALL MEDICATIONS MONITORED AND ADJUSTED REGULARLY BY YOUR PHYSICIAN. INITIALS

 

Contraindications, concerns for Hyperbaric Oxygen Therapy

1. CHF: Congestive heart failure

2. Current upper upper respiratory infections, chronic sinusitis, or sinus problems

3. History of Seizure or uncontrolled fever

4. Emphysema

5. History of thoratic surgery

6. Patients at risk for middle ear barotrauma (Ear/Sinus discomfort)

7. High blood pressure (poorly controlled)

8. Low blood sugar, or uncontrolled Diabetes

9. Had COVID and have shortness of breath or heart problems

10. Pregnancy

11. Untreated Pneumothrax (Lung problems)

12. Consumed alochol within the last 24hours

13. Claustrophobia

14. Cataracts

 

 

 

IF ANYONE GETTING IN THE CHAMBER IS SEIZURE PRONE, THE STAFF MUST BE MADE AWARE PRIOR TO THE FIRST VISIT. If a seizure is experienced while inside of the chamber, unless otherwise instructed (and a waiver is signed), our procedure is to call 911, remove the patient from the chamber and make the individual as comfortable as possible. DETOXIFYING OR CELL DIEOFF: Hyperbaric Oxygen Therapy may assist the body to naturally detoxify and balance digestive flora. AN INDIVIDUAL MAY EXPERIENCE SOME DISCOMFORT FROM THIS PROCESS IN AS LITTLE AS ONE TO THIRTY-SIX HOURS AFTER TREATMENT. Symptoms may include; flu like symptoms, loss of appetite, stomach ache, constipation, diarrhea, headache, behavioral issues etc. Although unpleasant, this is a natural process and continuing treatments may be of benefit to more rapidly accomplish a positive result.  IF SYMPTOMS PERSIST, WE RECOMMEND CONSULTING YOUR PHYSICIAN TO EVALUATE AND ALLEVIATE THE SITUATION BEFORE ATTEMPTING ANOTHER VISIT. PNEUMOTHORAX: Hyperbaric Oxygen Therapy is contraindicated for an existing Pneumothorax (collapsed lung). If you have experienced a Pneumothorax in the past and have already been “cleared from your doctor” to resume normal activity, once you have provided a written confirmation you should be able to proceed with Hyperbaric Therapy. DIABETES / INSULIN DEPENDANT: Insulin dependency may result in a drop in blood sugar while in the chamber. IMMEDIATELY COMMUNICATE TO THE STAFF IF YOU EXPERIENCE OR ANTICIPATE AN EPISODE. YOUR TREATMENT WILL BE TERMINATED. Please take a protein bar and a hard candy (or whatever you use if faced with a “drop” in the normal management of your condition) into the chamber with you.

SENSITIVITY TO CHEMICALS (MCS) / ODORS / ALLERGIES: Avoid wearing heavy or strong scented colognes/perfumes or deodorants as the smells may linger in the chamber and have an adverse effect on another patient. Smoke and other odors on your clothes are accentuated within the confines of the pressurized chamber. Try to minimize the detrimental effect of smoking on HBT results by abstaining within 1-hour pre and post treatment. 

 

* If you are uncomfortable in any way, or have any questions during your treatment session, you need to report them to the chamber operator immediately. We are here to help you to have a pleasant and satisfying session. Tell Staff immediately if you are taking the following medications: Bleomycin, Disulfiram, Mafernide Acetate Tell the staff immediately if you have or suspect you have: Hereditary Spherocytosis, Sickle Cell Anemia, COPD or Compressive brain lesion – subdural hematoma, intracranial hematoma: mild hyperbaric therapy is contraindicated for existing compressive brain lesions, if you have these conditions you must have a doctor’s clearance before use of our chamber. I have read and fully understand the above information.

 

Warning:

A very small number of patients having hyperbaric oxygen therapy develop temporary changes in eyesight. Studies have shown in these rare cases that any altered vision is of short duration and will return to pre-treatment status within six to eight weeks after the end of treatment. Hyperbaric oxygen therapy treatments can temporarily change the shape of the lens in the eye. This usually results in worsening myopia (nearsightedness), but improvement in presbyopia (the inability to focus on objects near the eye due to age-related changes in the lens).There will be a temporary change in the power of your eyes. Nearsighted may occur.

Studies have shown in these rare cases that any altered vision is of short duration and will return to pre-treatment status within six to eight weeks after the end of treatment. 

 

 

By giving informed consent I acknowledge to the services that will be provided. The undersigned hereby releases PuaManu  Medspa and its owner/officers and their agents from all claims and liabilities arising from the use or misuse of hyperbaric therapy indemnifying and holding institute and its agents harmless from all claims and liabilities wherefrom, whatsoever. In the unlikely event that the patient/undersigned has a dispute with PuaManu  Medspa and its agents the client agrees that the dispute shall be settled by arbitration only and that PuaManu  Medspa will never be liable for more than the cost of the HBOT session. I take responsibility for my own health and wellbeing and have sought out this wellness treatment after consulting with my doctor and/or healthcare provider. I agree that the time I spend with PuaManu  Medspa is valuable, and that if I need to cancel an appointment, I will do so at least 24 hours in advance. If I miss an appointment, I agree to pay the full appointment fee. PuaManu  Medspa may use health information about the sessions in the HBOT, as required for administrative purposes, and to evaluate the quality of care that you receive. PuaManu  Medspa will not disclose your information to others unless we have written authorization from you or unless the law authorizes or requires us to do so.

 I have read fully the above information on all intake documents and consent to sessions with the mild hyperbaric chamber (Treatment pressure is 1.3 ATA). I have also completed, read, and agree to this consent form and questionnaires which accompanies this consent form.