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Personal and Health History Intake Form




Please list current prescriptions:









I certify that all the answers and information provided by me above are accurate and correct.

October 21, 2020


INTAKE POLICIES


In an effort to provide superior care and personalized customer service, as well as to provide competitive rates, the following procedures have been established. These policies will ensure a satisfying experience for all our clients and guests.

Flying: Flying is prohibited for 12 hours following Hyperbaric Oxygen Therapy exposure.

Personal Belongings: For your convenience a storage area is provided for your personal items. O2 Health Lab is not responsible for lost or stolen items.

Scheduling: To allow for full convenience and flexibility, we recommend you schedule your services in advance. A valid credit card is required to reserve your appointment, however your card will not be charged until time of treatment, unless another payment method is chosen.

Arrivals: All first time clients must arrive at least 15 minutes prior to their scheduled appointment. Arriving early will allow you sufficient time as we require new Clients to fill out health history information and treatment consent forms.

Late Arrivals: Scheduling is designed to allow the correct amount of time to complete your service. In consideration to others, your service must end on time so the next client's appointment can begin as scheduled. If you are not able to be on time we will complete as much of your treatment as possible; however with some treatments it may be necessary to reschedule your appointment. This could result in a charge of the full value of your service.

Refunds: All completed treatments of a discounted package will be charged at full rate per treatment and an additional 10% will be charged of the package price of the balance to be refunded.

Cancellations: We understand sometimes you need to change or reschedule your appointment. We kindly ask that you provide us with a 24-hr prior notification for appointments and a 48-hr prior notification for Monday appointments. A "no show" and any appointment cancelled without proper notification will result in a charge of 100% of the scheduled treatment.

Payment: O2 Health Lab accepts Visa, MasterCard, Amex, cash and gift certificates. All service sales are final. All professional fees are to be paid in full prior to or at the time of treatment. The client is responsible for all service charges.

Termination and Referrals: O2 Health Lab reserves the right to refuse service at any time. I understand that O2 Health Lab is providing services at their discretion and may terminate my therapy at any time for any reason, and will charge me only for the sessions completed.

Please Sign Below

October 21, 2020


ARBITRATION AGREEMENT


Article 1 It is understand that any dispute as to malpractice against O2 Health Lab, LLC (“O2”), that is as to whether any services rendered under this contractual agreement were unnecessary or unauthorized, or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contractual agreement, by entering into it, are giving up their constitutional right to have such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2 I understand and agree that this Arbitration Agreement binds me and anyone else who may have a claim arising out of or related to all treatment or services provided by O2, including any spouse or heirs of the patient and any children, whether born or unborn at the time of the occurrence giving rise to any claim. This includes, but is not limited to, all claims for monetary damages exceeding the jurisdictional limit of the small claims court, including, without limitation, suits for loss of consortium, wrongful death, emotional distress, or punitive damages. I further understand and agree that if I sign this Arbitration Agreement on behalf of some other person for whom I have responsibility, then, in addition to myself, such person(s) will also be bound by this Arbitration Agreement, along with anyone else who may have a claim arising out of the treatment or services rendered to that person. I also understand and agree that this Arbitration Agreement relates to claims against O2, any physician, consenting substitute physician, partner, associate, association, corporation, partnership, or limited liability company affiliated by O2 and the employees, agents, and estates of any them. I also hereby consent to the intervention or joinder in the arbitration proceeding of all parties relevant to a full and complete resolution of any dispute arbitrated under this Arbitration Agreement, as set forth in the Medical Arbitration Rules of the California Medical Association and the California Hospital Association.

Article 3 I agree that the arbitrators have the same immunity from civil liability as that of a judicial officer when acting in the capacity of arbitrator under this Arbitration Agreement. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Article 4 I UNDERSTAND THAT I DO NOT HAVE TO SIGN THIS ARBITRATION AGREEMENT TO RECEIVE THE O2 SERVICES, AND THAT IF I DO SIGN THIS ARBITRATION AGREEMENT AND CHANGE MY MIND WITHIN 30 DAYS OF TODAY, THEN I MAY CANCEL THIS ARBITRATION AGREEMENT BY GIVING WRITTEN NOTICE TO THE UNDERSIGNED O2 STAFF MEMBER WITHIN 30 DAYS OF THE DATE OF MY SIGNATURE BELOW STATING THAT I WANT TO WITHDRAW FROM THIS ARBITRATION AGREEMENT.

Article 5 On behalf of myself and all other bound by this Arbitration Agreement as set forth in Article 2, agreed is hereby given to be bound by the Medical Arbitration Rules of the California Medical Association and the California Hospital Association, as they may be amended from time to time, which Rules are hereby incorporated by reference into this Arbitration Agreement. A copy of these Rules is included in this pamphlet, and additional copies are available from the California Medical Association, 1201 J Street, Suite #200, Attention: Publication Department, Sacramento, CA 95714 or at www.cma.org. I understand that disputes covered by this Arbitration Agreement will be covered by California law applicable to actions against health care providers, including the Medical Injury Compensation Reform Act of 1975 (including any amendments thereto).

Article 6 OPTIONAL: RETROACTIVE EFFECT. If I intend this Arbitration Agreement to cover services rendered before the date this Arbitration Agreement is signed, I have indicated the earlier date I intend this Arbitration Agreement to be effective from as confirmed by my initial immediately below.
Article 7 I have read and understand all of the information in this Arbitration Agreement, including the Rules. I understand that in the case of any pregnant women, the term “patient” as used herein means both the mother and the mother’s expected child or children.

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

NOTICE: BY SIGNING THIS ARBITRATION AGREEMENT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS ARBITRATION AGREEMENT.

I have read and understood the Arbitration Agreement, and I agree to be bound by the terms set forth in the Arbitration Agreement.

October 21, 2020


INFORMED CONSENT TO TREATMENT


Please read the below Contradictions and Rules for our Therapies and check each box to confirm you have reviewed the information.

Upon my authorization and consent, the therapies indicated above will be performed by an O2 practitioner. I hereby authorize O2 to treat me and to do all that is required as part of that therapy.

If any unforeseen conditions arise during the course of this treatment, I do hereby authorize and request the O2 practitioner and his/her assistants to perform such additional procedures and/or to render such treatment as s/he may in his/her professional judgment deem necessary.

I have read and understand all of the information regarding the specific therapy(ies) indicated above provided to me in writing by O2. The contraindications and rules for each therapy have been explained and I have been informed that I can refuse treatment.

All medical treatments carry the risk of unsuccessful results, complications, or injury from both known and unforeseen causes, and no warranty or guarantee is made as to result or cur.

I understand that, except in cases of emergency, therapies or treatments will not be performed on me until I have had the opportunity to receive the information described herein, ask questions of O2 staff and have those questions answered to my satisfaction, and have given my consent to the therapies or treatments.

By signing below, I indicate that:
▪ I have read and understand the information provided in this form and the information provided with this form specific to the therapy(ies) indicated above.
▪ My O2 practitioner has adequately explained the therapy(ies), along with the risks, benefits, and alternatives, and the other information described above in this form.
▪ I have had the chance to ask my O2 practitioner(s) questions.
▪ I have received all of the information I desire concerning the treatment or procedure.
▪ I authorize and consent to the performance of the therapy(ies) indicated above.

October 21, 2020

HYPERBARIC OXYGEN THERAPY

Contraindications

Do not undergo hyperbaric oxygen therapy if you have experienced any of the following:

● Nasal congestion, sinus problems, or a head cold
● Recent Dental (Last 24 Hours)
● Pneumothorax
● Pregnancy
● COPD

O2 Rules for Receiving Hyperbaric Oxygen Therapy

● Clearing your ears - While inside HBOT you must help clear your ears by equalizing the pressure you feel. You can clear your ears by the following:
■ Yawn and swallow
■ Valsalva (pinch your nose shut and attempt to gently blow through your nose)
■ Wiggle your jaw repeatedly (up and down, left to right, or in a circular motion)
■ If you will be utilizing a “sit up” chamber, you may chew gum
○ These techniques must be repeated every time you feel pressure building in your ears
○ If your ears do not clear using these techniques you MUST knock on the chamber so we can stop for a moment to let your ears adjust to the pressure
● If you have nasal congestion, sinus problems, or a head cold on the day of your treatment O2 recommends that you do not receive therapy on that day
● Wear cotton or a cotton blend in which cotton makes up at least 50% of that blend
● Socks must be worn
● Electronic devices and watches ARE NOT PERMITTED INSIDE THE HYPERBARIC CHAMBER
● No excessive makeup, perfumes, or skin lotion
● Empty all pockets before therapy
● If you have had any new dental work, especially fillings, you must wait 48 hours following such dental work before going in the chamber to preserve the integrity of the fillings
● Do not smoke at least four hours prior to and following your treatment.
● DO NOT FLY OR DRIVE TO A HIGHER ALTITUDE within twelve hours following the completion of a treatment.
● If you have any questions regarding your medications, consult your hyperbaric technician

WHOLE BODY CRYOTHERAPY

Contraindications

Do not undergo cryotherapy if you have experienced any of the following:

● Pregnancy
● Severe hypertension (BP> 180/100)
● Acute or recent myocardial infarction
● Unstable angina pectoris
● Arrhythmia
● Symptomatic cardiovascular disease
● Cardiac pacemaker
● Peripheral arterial occlusive disease
● Venous thrombosis
● Acute or recent cerebrovascular accident
● Uncontrolled seizures
● Raynaud’s Syndrome
● Fever
● Tumor disease
● Symptomatic lung disorders
● Bleeding disorders
● Severe anemia
● Infection
● Claustrophobia
● Cold allergy
● Acute kidney and urinary tract diseases
● TBI

O2 Rules for Receiving Whole Body Cryotherapy

● You must wear cotton or wool socks (and underwear in men) to avoid chilblain.
● Wet or damp clothing cannot be worn at any time
● Treatments are limited to 3 minutes per session. Overexposure to the cold temperatures may cause chilblain.
● During treatment, you must avoid inhaling the nitrogen fumes; while nontoxic, they are devoid of oxygen and may cause fainting.
● During treatment, you must keep your hands visible to the operator at the upper rim of the cryocabin as instructed.
● You may end the procedure at any time if you experience any problems or anxiety.
● Abnormal skin sensitivity to cold may be caused by certain foods, cosmetics, or medication, including but not limited to the following: tranquilizers, and high blood pressure medication.

LOCAL CRYOTHERAPY

Contraindications

Do not undergo local cryotherapy if you have experienced any of the following:

● Cryoglobulinemia
● Cold agglutination
● Cold induced hemoglobinuria
● Cold urticaria
● Cold hypersensitivity
● Reynaud’s phenomenon
● Aesthesia disorders
● Significant anemia
● Congelation dermatitis
● Tissue microvasculature disorders
● Serious heart and vascular diseases
● Neurological diseases, paresthesia, polyneuropathies
● Diseases with fever
● Herpes
● Lesions (including fresh burns)
● Pregnancy
● Sinusitis
● Acne rosacea
● TBI

INFRARED SAUNA THERAPY

Contraindications

Do not undergo infrared sauna therapy if you have experienced/are experiencing any of the following:

Cardiovascular Issues, Obesity or Diabetes
Intoxication
Prescription Medications
Alcohol and Drug Abuse
Chronic Conditions/Diseases Associated With Reduced Ability to Sweat or Perspire
TBI
Hemophiliacs/Individuals Prone to Bleeding
Fever and Insensitivity to Heat
Pregnancy
Menstruation
Joint Injury
Implants
Pacemakers/Defibrillators/Surgical implants of any kind
Sustained injury within last 48 hours

O2 Rules for Receiving Light Therapy

● No one under the age of 18 is allowed in the sauna unless accompanied by a supervising adult
● Discontinue the sauna if you feel light-headed, dizzy or heat exhaustion
● Sauna sessions should be limited to no more than 40 minutes and temperatures should stay below 150 degrees Fahrenheit
● Clients using any medications must consult a physician or pharmacist prior to use of the sauna
● Pregnant women should consult a physician prior to use of the sauna
● Never sleep inside the sauna while it is on
● Do not stack or store objects above on top or inside the sauna
● Do not use during an electrical storm, as there is a remote risk of shock
● Altering or tampering with any electrical connections to power supply is dangerous

BEMER PULSED ELECTROMAGNETIC FIELD THERAPY

Contraindications

You should avoid using PEMF if:

● You have a pacemaker, cochlear implant, intrathecal pump
● You have had an organ transplant

AVACEN THERMO THERAPY

Contraindications

Talk to doctor before using AVACEN thermo therapy if you are/have any of the following:

● Under 18
● Pregnant
● Have a temperature higher than 99.5 degrees Fahrenheit
● Malignancy
● Chronically hot or swollen joint in the hand, fingers or wrist
● Circulatory diseases
● Recent acute joint injury in the hand, fingers or wrist

O2 Rules for Receiving Avacen Thermo Therapy

● DO NOT USE:
○ On a hand with open sores or wounds
○ On sensitive skin areas or in the presence of poor circulation
○ With liniment, salve or ointments
● Remove all jewelry (rings, bracelets, watches) from the hand that will be used for therapy
● Metal implants - pay attention for signs of any uncomfortable heat buildup in the treatment area. If this occurs, stop using the device.
● If the unit does not turn off when the On/Off Button is pressed, unplug the unit.

AIR RELAX RECOVERY COMPRESSION THERAPY

Contraindications

You should avoid using compression therapy if you have the following:

● Acute thrombophlebitis
● Acute pulmonary edema
● Acute congestive cardiac failure
● Acute infections
● Deep vein thrombosis (DVT)
● Episodes of pulmonary embolism
● Wounds, lesions, or tumors at or near the site of application
● Where increased venous and lymphatic return is undesirable
○ Bone fractures or dislocations at or near the site of application

PHOTOBIOMODULATION LIGHT THERAPY

Contraindications

You should avoid using compression therapy if you have the following:

● Acute or Cutaneous Porphyria
● Diabetes
● Lupus Erythematosus
● Thyroid Problems
● Photophobia
● Exogenous Eczema
● Epilepsy and seizure prone
● Hypomelanism
● Skin cancer (melanoma)
● Eye disease
● Migraines
● Asthma
● Heart trouble (pacemaker)
● Cirrhosis of the liver
● Blood thinners
● Brain injury (hemorrhage)
● Pregnant

O2 rules for receiving Air Relax recovery compression therapy

● Clearing your ears - While inside CVAC you must help clear your ears by equalizing the pressure you feel. You can clear your ears by the following:
■ Yawn and swallow
■ Valsalva (pinch your nose shut and attempt to gently blow through your nose)
■ Wiggle your jaw repeatedly (up and down, left to right, or in a circular motion)
■ These techniques must be repeated every time you feel pressure building in your ears
○ If your ears do not clear using these techniques you MUST knock on the chamber so we can stop for a moment to let your ears adjust to the pressure

October 21, 2020


Assumption of Risk, Waiver and Release of Liability, and Hold Harmless Agreement


1. In consideration for using the equipment (the “Equipment”) and receiving the services related to Hyperbaric Oxygen Therapy, Whole Body Cryotherapy, Local Cryotherapy, Light Therapy, Bemer PEMF, Avacen, Infrared Sauna, Air Relax Compression, and/or other therapies (collectively, “Therapy”) from O2 Health Lab, LLC (“O2”), I hereby release, waive, discharge, and hold harmless O2 and its officers, members, managers, employees, contractors, representatives, and agents (the “Releasees”) from any and all liability, claims, demands, actions, and causes of action arising out of or relating to any loss, damage, or injury that may be sustained by any person while using the Equipment, due to the use or misuse of the Equipment, or in relation to Therapy.

2. I hereby understand and confirm that no warranty, guarantee, or other assurance has been made to me covering the results of Therapy, and I hereby relieve the Releasees and hold them harmless from all liabilities for injury or damage that may occur to me. I full understand the administration of Therapy, including possible adverse reactions, side effects, or other possible complications. It is understand that this agreement is being made in advance of any administration of Therapy or use of the Equipment and is being given by me voluntarily to use the Equipment.

3. I am fully aware of the risks and hazards connected with the use of the Equipment, including the risk of physical injury or disability as a result of such injury, and I am voluntarily participating in said Equipment usage, and entering the O2 premises to engage in such usage. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY that may be sustained as a result of being engaged in such an activity.

4. I further agree to indemnify and hold harmless the Releasees from any loss, liability, damages, or costs that O2 may incur due to my use of the Equipment.

5. This agreement shall bind the members of my family and my spouse (if any), and my heirs, assignees, and personal representatives, and shall be deemed a release, waiver, and discharge of the Releasees.

6. I understand that the Releasees will not be responsible for any medical costs associated with any injury sustained in connection with the use of the Equipment. I understand that Therapy is provided for the basic purposes of relaxation, stress reduction, relief of muscular tension, recovery from muscular tension, recovery from surgery, illness, or injury, and is only appropriate for those in proper health. I further understand that Therapy should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician or other qualified medical specialist for physical or mental ailment of which I am aware. I understand that the O2 therapists providing Therapy are not qualified to diagnose medical conditions or prescribe medications, and that nothing in the course of any Therapy session should be construed as such.

7. Because Therapy is contraindicated under certain conditions, I affirm that I have stated all my known medical conditions and answered all personal and medical questions honestly. I agree to keep O2 updated as to any changes in my medical or personal information and understand that O2 shall not be liable for my failure to disclose or update my medical or personal information fully.

I understand the proper use of the Equipment. I represent that I am at least 18 years old and fully competent to execute this agreement. I agree to comply with all instructions on the use of Equipment and in receiving the Therapy and that I am using these services at my own risk. I have read and understood the foregoing Assumption of Risk, Waiver and Release of Liability, and Hold Harmless Agreement, and I agree to be bound by the terms set forth in this agreement.

October 21, 2020


COVID-19 Informed Consent


I understand in-office visits and receiving services from O2 Health Lab, despite my own efforts and those of O2 Health Lab, may increase the risk of my exposure to COVID-19. I am aware that exposure to COVID-19 can result in severe illness, intensive therapies, ventilator support, life-altering changes to my health, and even death. Being fully informed, I consent to receiving services and treatments from O2 Health Lab and accept the risk of COVID-19 exposure. I agree to bear the cost of any COVID-19 treatments, should they be required for myself. I have been given the opportunity to postpone my in-person visits and treatments, but I choose to have my treatments performed now.

I confirm neither I, nor any individual living with me, has any of the COVID-19 symptoms listed by the Centers for Disease Control. I understand I must honestly disclose this information to avoid putting myself and others at risk. I accept that O2 has implemented infection-control procedures with which I must comply, for my own protection as well as that of O2 Staff and other O2 Clients. I understand my cooperation is mandatory, whether or not I personally feel such COVID-19 procedures and/or preventive measures are necessary.

All topics above have been discussed with me, and all my questions have been answered to my satisfaction. If I am the parent, guardian or conservator of the client, I have read this COVID-19 Informed Consent Agreement and am authorized to consent on the client's behalf.

October 21, 2020