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INFORMED CONSENT
FOR HYPERBARIC OXYGEN THERAPY
I, _________________________, give my
consent to Richmond Hyperbaric Health Center Inc. to administer
Hyperbaric Oxygen Therapy to _____________________. In doing so, I
acknowledge that I have been advised of the
following:
I acknowledge that Hyperbaric Oxygen
Therapy is considered the primary therapy for several conditions
such as decompression, gas gangrene, and carbon monoxide poisoning,
and as such is generally accepted and recognized as effective in the
medical community.
Many physicians consider its use “investigational” when used
to treat certain illnesses, injuries, and disorders. These may
include stroke, cerebral palsy, multiple sclerosis, Crohn’s disease,
Lyme disease, or other conditions for which there is strong,
published evidence of its effectiveness.
Richmond Hyperbaric Health Center Inc.
will administer Hyperbaric Oxygen Therapy as treatment for the
following condition(s).
_______________________________________________________________
_______________________________________________________________
Although such condition(s) are
indications for Hyperbaric Oxygen Therapy recognized and accepted by
a growing number of doctors, treatment of such condition(s) may
not be generally recognized and accepted as effective by the
medical community.
Thus, I understand the therapy to which I am agreeing may be
characterized as “investigational”.
The known risks of Hyperbaric Oxygen
Therapy include: temporary visual changes (near sightedness), ear
pressure – sinus squeeze (similar to pressure changes experienced
during an airplane flight), fire hazard (highly unlikely), seizure
(again very unlikely), and confinement anxiety (claustrophobia).
These risks have been fully explained to me. I have had the
opportunity to ask and all answers to my questions were to my
satisfaction regarding all aspect of this treatment.
Any additional risks to my particular treatment
include:
_______________________________________________________________
_______________________________________________________________
No representations have been made to me by representatives or
any other person associated with Richmond Hyperbaric Health Center
Inc. implying that treatments to which I hereby consent will produce
any specific result or benefit. This therapy in children is
investigational. No representations have been made except as set
forth in this Informed Consent concerning the accuracy, validity or
efficacy of Hyperbaric Oxygen Therapy.
I acknowledge the costs of performing
Hyperbaric Oxygen Therapy as described in the Payment Policy and
therefore fully understand and expressly agree that I will be
personally responsible for the full cost of services received from
Richmond Hyperbaric Health Center Inc.
Dated this ____________________day of
________________,
____________________
Patient or Guardian__________________________
Witness____________________
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