Client Medical Intake Form

First Name*(Required)

Last Name*(Required)

Health Card #

Address*(Required)

City*(Required)

Province*(Required)

Postal Code*(Required)

Date of Birth*(Required)

Gender*(Required)

Male

Female

Other

Mobile Phone*(Required)

Home Phone

Email*(Required)

Family Physician Name

Family Physician Phone

Referred by Name

Referred Phone

Emergency Contact Name*(Required)

Emergency Contact Phone*(Required)

How did you hear about us?

Referring MD/Provider

Website

Social media

Newspaper/Journal/Flyer

Scrub Size*(Required)

X-Small

Small

Medium

Large

X-Large

Large (2XL to 5XL)

Large Scrub Size(Required)

(Size is required for the 100% cotton scrubs provided by the clinic for treatments)

Health Details

Indication / condition you are seeking HBOT treatment for:*(Required)

How long have you had this condition?

Any other health concerns you are having?

Medications / OTCs (over the counter meds)/supplements you are currently taking including dosage:*(Required)

If currently not taking any, please put “none”

Have you ever used hyperbaric oxygen therapy treatments in the past or recently? If yes, what was the indication/condition you were treating? Were you in a multi-place chamber or a mono-place chamber?

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