New Patient 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 / InstagramWord of Mouth

Who can we thank for referring you? *

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Name *

First

Last

Date of Birth (MM/DD/YYYY) *

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Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

MEDICAL HISTORY

Do you have a specific injury? If so, please include the date. *NoYes

If yes, please provide details

Do you have any Implants? *NoYes

How did you hear about us?

Are you curently receiving medical treatment? *NoYes

If yes, please provide details

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

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Are you currently taking any medication? *NoYes

If yes, please provide details

Have you ever suffered a serious illness or injury? *NoYes

If yes, please provide details

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

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EMERGENCY CONTACT

Emergency Contact Name *

First

Last

Phone *

Relationship *

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

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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

Enter todays date

Signature

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