INFORMED CONSENT TO TREATMENT
Upon my authorization and consent, the therapies indicated below 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 below 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.
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
Please read the above Contradictions and Rules for our Therapies and check each box to confirm you have reviewed the information. 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.
* By signing, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By signing here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
January 27, 2021