Blessed Hands IV Hydration and Wellness LLC
Hyperbaric Oxygen Therapy (HBOT) Consent Form

Patient Name:  
Date of Birth: 

Hyperbaric Oxygen Therapy (HBOT) involves breathing oxygen in a pressurized chamber to promote
healing, improve oxygenation, and support overall wellness.

Purpose / Benefits of HBOT:
HBOT may be used for enhanced wound healing, improved tissue oxygenation, support of recovery
from certain medical conditions such as chronic fatigue or non-healing wounds, reduction of
inflammation, and general wellness including improved cellular function.

Risks and Possible Side Effects:
While HBOT is generally safe, possible risks include ear or sinus barotrauma (pain or injury due to
pressure changes), temporary vision changes, fatigue or lightheadedness, claustrophobia or
anxiety inside the chamber, oxygen-related complications (rare), fire hazard (extremely rare if safety
protocols are followed), lung injury (rare), and other unforeseen complications.

Contraindications:
HBOT may not be suitable for individuals with certain medical conditions including untreated
pneumothorax, severe respiratory infections, certain types of ear or sinus disorders, and pregnancy
unless approved by a physician. Please disclose all medical conditions to staff prior to therapy.

Acknowledgment of Risks and Liability Release:
I acknowledge that I have been informed of the potential benefits and risks of HBOT. I understand
that Blessed Hands IV Hydration and Wellness Center, LLC, and its staff have explained the
procedure, benefits, and risks to me. I understand that no guarantee has been made regarding the
outcomes of HBOT. I voluntarily consent to undergo HBOT. I release, waive, and hold harmless
Blessed Hands IV Hydration and Wellness Center, LLC, its owners, agents, and employees from any
liability, claims, or damages arising from my participation in HBOT, except in cases of gross
negligence or intentional misconduct. I agree that any legal action related to HBOT must first
attempt resolution through mediation or arbitration, and I waive my right to file suit in civil court
against the facility or its staff.

Emergency Protocol:
I understand that in the event of an emergency during HBOT, staff will provide appropriate medical
intervention or contact emergency services.

Patient Consent:
I have read and fully understand this consent form. All my questions have been answered to my
satisfaction. I voluntarily consent to HBOT under the terms described above.