Client Intake form

Intake Form

Yes   No
Add More
Yes   No
Add More

Checklist Concerns

High blood pressure or taking blood pressure medication*:
Yes  

No
Ear or sinus disease (including infections and/or surgery)*:
Yes  

No
Asthma*:
Yes  

No
Claustrophobia*:
Yes  

No
Cataracts*:
Yes  

No
Seizure disorders/epilepsy*:
Yes  

No
Uncontrolled high fever*:
Yes  

No
Diabetes or poor blood sugar control*:
Yes  

No
Congenital Spherocytosis or sickle cell anemia*:
Yes  

No
Lung disease/damage, COPD, emphysema, collapsed lung, or fluid in the lungs, pneumonia, COVID lungs, lung cancer, pulmonary fibrosis, severe shortness of breath)*:
Yes  

No
History of chest surgery*:
Yes  

No
Are you currently pregnant or potentially pregnant *:
Yes  

No
Cancer*:
Yes  

No
Heart Failure*:
Yes  

No
Do you have any implanted medical devices? This includes pacemakers, deep brain stimulation, and all other electronic medical device implants*:
Yes  

No

Select Purchase

Safety Screening Report only $0$99 ($99 will be billed to The Fix Aspen*)

Many doctors are either not trained or do not feel comfortable signing a hyperbaric prescription. This report should help your doctor with this process. We recommend that you take this report to your doctor/healthcare provider and it includes a physician statement on the last page of the report that your doctor can sign. If your doctor would like you to speak to one of our O2 providers about your risk assessment report, there will be no extra charge for this service - Safety is our number 1 priority.

I would like to add O2 Provider support:

A Professional Assessment (includes safety screening report) $50$199 ($149 will be billed to The Fix Aspen*)

A licensed, hyperbaric-trained, healthcare practitioner will give you and/or your doctor their professional assessment (as to your level of fitness for being inside a hyperbaric chamber). This assessment is based on your online intake form and the answers that you have submitted. Note, you may receive a phone call from the O2 Providers before he/she gives their assessment.

A Signed Physician Statement (includes safety screening report) $195$349($154 will be billed to The Fix Aspen*)

A licensed, hyperbaric-trained, practitioner will consult with you to review your hyperbaric safety screening report, answer any questions that you have, and sign the physician statement on the last page of safety screening report. In addition, you will receive full access physician support while you are undergoing hyperbaric therapy for up to 3 months, where you and your doctor have conceirge access to for any question or concerns that occur during your HBOT sessions.

* Coupon applied from The Fix Aspen

Consent Form

Consent for Hyperbaric Safety Screening for General Health and Wellness

“O2 Providers” is part of Wellness Without Limits LLC, a Florida based company. Zayd Ratansi, ND serves as the hyperbaric advisor and all other O2 Providers are independent healthcare practitioners trained in hyperbaric therapy.

Safety Screening Report

By choosing the safety screening report then:
  • I understand that this report is a “general risk assessment report” for hyperbaric oxygen therapy and the results of this report are solely based on my answers to the hyperbaric screening questionnaire on the online intake form.
  • I have accurately and to the best of my knowledge filled out the Intake Form for the hyperbaric screening online application.
  • I understand that this report is not a prescription and will not be signed by an O2 provider. If I wish to proceed with hyperbaric therapy, then I will take this report to my doctor and get him/her to sign the physician statement before I begin hyperbaric therapy.

Professional assessment — From an O2 Provider

O2 providers are independent licensed healthcare practitioners trained in hyperbaric therapy and an O2 provider may or may not call you if they have questions based on these answers. If I choose to have an O2 provider review my screening report and give their professional assessment of my fitness for undergoing hyperbaric therapy then:

  • I understand that this is a “assessment for hyperbaric fitness” and the results of this assessment are solely based on my answers to the hyperbaric screening questionnaire on the online intake form.
  • I have recently been evaluated within the past 6 months by a licensed medical doctor for my health (and have not had any changes in my health status since this evaluation) and have accurately filled out any diagnosis of any medical condition or any medication that I have been prescribed and made this aware and in detail during this screening process. This includes any changes in health or medication status since my last doctors visit.
  • Since both past and current medical history are pertinent and of primary importance to proper safety screening, I hereby agree that I will accurately disclose all truthful information to O2 Providers and hold harmless Wellness Without Limits LLC, Dr. Ratansi ND and all O2 providers should I fail to provide necessary information for safe and proper administration. “Necessary information” includes, but is not limited to, any safety screening medications, controlled substances, alcohol, homeopathic remedies, vitamins, and any other over-the-counter items that I am currently taking that could affect my sessions inside the chamber.
  • If I am assessed for being “fit” to be inside a hyperbaric chamber by an O2 provider, then I agree to immediately let my current physician know and get their recommendation before proceeding
  • If I am using this assessment for:
    • General Health and Wellness, then I understand that it is only to try to help me to improve my physiologically available levels of oxygen, with the primary goal to help support my body for optimal cellular functioning.
    • A Medical condition, then I will first take this assessment, along with the full safety screening report, to my doctor so that he/she can sign the physician statement on the last page of the safety screening report.

Physician Statement — From an O2 Provider

At this time, only Dr Ratansi, ND will be providing consultations for signed Physician Statements . If I choose to have a hyperbaric consultation with Dr. Ratansi to sign my paperwork then:

  • I understand that this will be a Telehealth consultation and will not be seeing Dr. Ratansi in person and the paperwork will be from Dr. Ratansi’s Naturopathic License in the state of California.
  • I understand that not all California hyperbaric centers will accept the signed statement from Naturopath so I will check with my center and their medical screening process.
  • I will take the physician statement along with the full report for final approval and signature from my doctor
  • I have recently been evaluated within the past 6 months by a licensed medical doctor for my health (and have not had any changes in my health status since this evaluation) and have accurately filled out any diagnosis of any medical condition or any medication that I have been prescribed and made this aware and in detail during this screening process. This includes any changes in health or medication status since my last doctors visit.
  • Since both past and current medical history are pertinent and of primary importance to proper safety screening, I hereby agree that I will accurately disclose all truthful information to O2 Providers and hold harmless Wellness Without Limits LLC, Dr. Ratansi ND and all O2 providers should I fail to provide necessary information for safe and proper administration. “Necessary information” includes, but is not limited to, any safety screening medications, controlled substances, alcohol, homeopathic remedies, vitamins, and any other over-the-counter items that I am currently taking that could affect my sessions inside the chamber.
  • If I am using this physician statement for:
    • General Health and Wellness, then I understand that it is only to try to help me to improve my physiologically available levels of oxygen, with the primary goal to help support my body for optimal cellular functioning.
    • A Medical condition, then I will first take this signed document, along with the full safety screening report, to my doctor so that he/she can make a final approval.
I affirm that I am and that the information given on this form is true and correct
Please wait...
Click Here to enter coupon

Enter Your Card Details

Submit

Email