Hyperbaric Therapy Intake Form

Thank you for choosing to work with Aloha Spa! We will strive to provide you with the best possible hyperbaric therapy service. 

To help meet all of your needs, please take some time and fill this form out completely (4 pages). If you have any questions or need clarification, please ask at the reception desk. We will be happy to assist you!

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Tell the staff immediately if you are taking the following medications:

Bleomycin, Disulfiram, Mafenide Acetate

Tell the staff immediately if you have or suspect you have:

Hereditary Spherocytosis, Sickle Cell Anemia, COPD, Pregnancy
Full Name
Address (including Zip code)
Birth Date
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Phone Number
Email
Emergency Contact
Emergency Contact Phone
Are you currently under a doctor's care?
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Physician's Name:
Physician City/State

I give permission to Aloha Spa to send me text messages, call my phone, and send me emails.

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How did you hear about Aloha Spa?

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