Consent for the Hyperbaric Chamber – Acknowledgements

Consent for the Hyperbaric Chamber – Acknowledgements


1. I am requesting to use the hyperbaric chamber at Heavenly Salt Therapy. I understand this is NOT a medical treatment and is only being used for general wellness. (Do NOT stop any current treatments your Dr. has prescribed).


2. The staff has explained to me the nature of a hyperbaric chamber, the possible risks, discomforts and complications. He/she answered all the questions I may have concerning the usage. I understand that Heavenly Salt Therapy makes no representations, claims, or guarantees.  


3. I understand and acknowledge all the risks associated with a hyperbaric chamber: Including: Barotrauma (to include ear squeeze, sinus squeeze and pulmonary overpressurization) with or without Pneumothorax, subcutaneous emphysema, or pneumomediastinum; visual changes; and sound injury to ears. 


4. I am aware and I acknowledge that NO GUARANTEES HAVE BEEN MADE TO ME AS TO THE RESULT OF THE USAGE. 


5. I understand that this is NOT a medical treatment and therefore is NOT covered by insurance and as the client I am responsible for all payment to Heavenly Salt Therapy for the services provided.


6. I will inform my primary care physician that I am using a hyperbaric chamber and will ask any medical related questions directly to them. 


7. I have read, had explained to me, and understand the above consent. I accept full responsibility for the risks or complications that might occur.  


8. I acknowledge that I must give 24 hour notice if I am to miss an appointment. If I fail to do so, I acknowledge that I will be charged for the treatment for that day. 


9. I am not pregnant and understand that I need to make staff aware if this changes. 


10. I assume any and all risk and I indemnify Heavenly Salt Therapy. I choose to undergo the treatment or modality; accordingly, I knowingly, voluntarily, and intelligently assume risks involved in the same. As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Heavenly Salt Therapy from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the services described above, or arising out of or in connection with referral to other practitioners or modalities. Correspondingly, I agree not to pursue a claim against any of the foregoing, merely because I am dissatisfied with the results of the above services. 


11. Any dispute, claim, or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration in  Sacramento, California, before one (1) arbitrator.  The arbitration shall be administered by AHLA Alternative Dispute Resolution Service Rules of Procedure for Arbitration. Judgment on the award may be entered in any court having jurisdiction.  This provision shall not preclude either party from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction.  The arbitrator may, in the award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator.  Each party has read and understood this Section (Arbitration) and understands that it thereby agrees to submit any claims arising out of this Agreement to binding arbitration, and that this dispute resolution provision constitutes a waiver of the Party’s right to a jury trial. HOWEVER, prior to either party initiating Arbitration of any dispute, the parties agree to attempt mediation of the dispute with a mutually agreeable trained mediator. “Trained mediator” means a professional with actual training and experience in the field of Mediation and/or dispute resolution. EACH PARTY HAS READ AND UNDERSTANDS THIS SECTION and UNDERSTANDS THAT BY SIGNING THIS AGREEMENT, THE PARTY AGREES TO SUBMIT ANY CLAIMS ARISING OUT OF, RELATING TO, OR IN CONNECTION WITH THIS AGREEMENT, OR THE INTERPRETATION, VALIDITY, CONSTRUCTION, PERFORMANCE, BREACH, OR TERMINATION THEREOF TO MEDIATION AND ARBITRATION, AND THAT THE DISPUTE RESOLUTION PROVISIONS SET FORTH IN THIS SECTION CONSTITUTE A WAIVER OF THE PARTY’S RIGHT TO A JURY TRIAL.  


CONTRAINDICATIONS

 

Untreated Pneumothorax – A pneumothorax is a condition where air or gas is trapped in the chest cavity. If a person undergoes HBOT, further damage to the lungs can occur.

 

Prescription Medications - Patients should not have hyperbaric oxygen therapy if they are currently or have recently taken any of the following medications:

 

Doxorubicin (Adrianmycin) (AdrimycinR) - This is a chemotherapy drug. There is a three day waiting period after you have taken this drug to have it safely clear your body as cardiotoxicity may occur to treat at deep depths.

 

Disulfiram (AntabuseR) - This drug is used in treating alcoholism. It may impair the body’s natural defense against oxygen toxicity. There is a seven day waiting period after you have taken this drug to treat at deep depths.

 

Cis-Platinum - This drug is used in cancer treatments. It impairs the wound healing. There is a seven day waiting period after you have taken this drug to have it safely clear your body.

 

Mafenide Acetate (SulfamylonR) - This is an antibacterial cream used to suppress infection in burn patients. It can encourage CO2 build-up, impairing wound healing. Patients using this cream should have all of the cream removed. Silver Sulfadiazene (FlamazineR) is an effective substitute and is compatible with HBOT.

 

Asthma – It could result in a pneumothorax.

 

Cataracts - May exacerbate existing cataracts.

 

Chronic sinusitis – It could lead to possible barotrauma.

 

Congenital spherocytosis – Hemolysis might occur due to fragile red blood cells.

 

Claustrophobia – It might lead to increased anxiety. 

 

Dental Work- All dental work, root canals, fillings must be complete. A dental baro-trauma could occur causing a painful condition. Please let us know if you have any temporary dental caps or unfinished root canals.

 

Diabetics - Insulin levels need to be monitored before treatments. During the treatment the patient’s sugar levels will decrease. If the level is too low prior to treatment, the patient will need to eat something in order to increase their level.

 

Emphysema with CO2 retention - It might present a risk of pneumothorax.

 

High blood pressure - HBO therapy acts as a vasoconstrictor because it slightly narrows or constricts blood vessels. This results in a patient's blood pressure can slightly raise during treatment. Therefore, if the patient’s blood pressure is too high the patient may not be treated that day unless it is an emergency situation

 

High Fever – It could lower the threshold for seizures; temperature should be lowered before attempting therapy.

 

History of ear surgery – Patient might not be able to clear their ears and increase the risk of trauma to the ear with forced clearing. An ENT might need to be consulted.

 

History of seizures – It lowers the threshold for seizures. An increase in medication might be recommended.

 

Optic Neuritis – Rare cases of worsening vision and blindness have occurred.

 

Pacemakers – There is a possibility of malfunction of SOME pacemaker devices. **Manufacturer must be contacted for pressure verification prior to therapy**

 

Pregnancy –It is unknown if any stress is caused to the fetus. 

 

Recent Eye Surgery/Retinal Detachment - HBOT can temporarily change the shape of the lens in the eye thus causing potential damage.

 

Thorax surgery – There is a small risk of air trapped in scarring caused during surgery.

 

Upper respiratory infections – Patients might have trouble clearing their ears that result in trauma to the ear.

 

Potential Side Effects

 

Serous Otitis Media: An acute or chronic collection of fluid in the middle ear, where fluid cannot drain down the Eustachian tube, either because of an upper respiratory infection or an attack of nasal allergy or from long standing Eustachian tube blockage. This fluid may have thickened so that it cannot be absorbed or drained easily. Hearing is diminished, similar to having “cotton in the ears.” Normal hearing returns after a few weeks when the fluid is drained. Sinus decongestants may help alleviate the blockage.

 

Visual Refractory Changes: Over multiple treatments, pressure can also temporarily affect the lens of the eye and vision may worsen or improve. Typically, patients with presbyopia may notice a vision improvement; those with myopia may notice blurriness. Each of these refractory changes reverts to pre-hyperbaric condition usually within 6 weeks after cessation of therapy.

 

Alternobaric Vertigo: A sudden brief disorientation may occur when the pressure is reduced at the end of a treatment, especially if you get up very quickly.

 

Confinement Anxiety: Rarely patients experience anxiety during treatments. Calming techniques can be employed to reduce the anxiety and if necessary and appropriate, a mild sedative may be taken before treatment.

 

Numbness in fingers: Very rarely tingling in the fourth and fifth fingers of the hands has occurred in a small percentage of patients. This disappears a few weeks after cessation of therapy.

 

Detoxifying or cell dieoff: HBOT may assist the body to naturally detoxify and balance digestive flora. AN INDIVIDUAL MAY EXPERIENCE SOME DISCOMFORT FROM THIS PROCESS IN AS LITTLE AS 1 TO 36 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. However IF SYMPTOMS PERSIST, WE RECOMMEND CONSULTING YOUR PHYSICIAN.

 

I have read this consent and I am fully aware of the potential risks associated with a Hyperbaric Chamber. I have disclosed any and all contraindications to Heavenly Salt Therapy and its staff.

 

 

 

Who will be participating?

Adult  Adult and Children  Children

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