New Client Appointment

HEAL FASTER – NATURALLY

And hey, rest assured, your data’s in safe hands – all our online forms are super secure and HIPAA compliant. Should you need any assistance, just give us a call at 757-770-1005, and we’ll be your trusty guides on this thrilling journey with Hyperbaric Health!

This form is only for Hyperbaric Oxygen therapy! If you require another type of appointment, call us.

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– Step 1 of 3

When would you like to make your appointment with us? *In the next 1-7 daysIn the next 14 – 30 daysIn 30 days or more?

We will need our form below completed prior to your free consultation.

How did you hear about us? *GoogleFacebook / InstagramStreaming TVWord of Mouth

Who can we thank for referring you? *

First Name *

Last Name

Date of Birth (MM/DD/YYYY) *

Address *

Address Line 1

Address Line 2

City

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Zip Code

MEDICAL HISTORY

Do you have a specific injury? If so, please explain. If no, write 'NO.' *

Are you currently taking any medication? If so, please explain. If no, write 'NO.'

Email *

Mobile Phone *

We send text messaging reminders for appointments and communications. By submitting this form you authorize us to communicate with you via text and voice.

Sex *MaleFemaleI identify a different wayOtherPrefer not to say

Are you currently receiving medical treatment? If so, please explain. If no, write 'NO.'

Do you have any implants? If so, please explain. If no, write 'NO.' *

Have you ever suffered a serious illness or injury? If so, please explain. If no, write 'NO.'

Next

Do you have asthma or other lung issues? *NoYes

If yes, please provide details

If yes, you will need chest x-ray & medical clearance for HBOT.

Do you have any other allergies? *NoYes

If yes, please provide details

Any other disabilities or conditions not mentioned above? *NoYes

If yes, please provide details

Next

EMERGENCY CONTACT

Emergency Contact Name *

First

Last

Phone *

Relationship *

I attest the information I’ve provided is true and correct.

Accept Terms *

• I agree to to terms and conditions

By Signing this form I agree to electronic signature. I attest the information provided is true and correct.

HIPPA Compliance *

• I agree to to HIPPA Disclosures

Date

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