and PATIENT CONSENT TO WOUND CARE HYPERBARIC OXYGEN THERAPY (HBO) therapy is a medical treatment in which the entire body is exposed to increased atmospheric pressure while the patient breathes 100% oxygen.

The breathing of oxygen while in a television, listen to music, sleep, or pressurized environment stimulates just rest during the remainder of the the body mechanisms to promote treatment, which usually lasts about healing. two hours. There is very little sensation while At the end of your treatment, the undergoing HBO therapy. During pressure will gradually decrease PURPOSE OF TREATMENT: pressurization you will get a as the chamber ascends over a 1. A generalized constriction of blood “fullness” buildup in your ears as a period of 10-15 minutes. During this vessels that decreases edema or result of the pressure change. This decompression you will experience swelling. feeling is similar to diving down to a popping sensation in your 2. Activation of the immune system to the bottom of a swimming pool, ears as a result of the decreasing fight and kill certain bacteria. driving through the mountains or pressure. This popping is a normal 3. Stimulation of cells to rebuild tissues flying in a plane. The hyperbaric adjustment inside your ears. and enhance healing. nurse will show you how to relieve Generally, you experience no after 4. Inactivation of toxic materials this fullness so that you can avoid effects from HBO therapy. However, produced by bacteria. discomfort during your treatment. some patients report a crackling 5. Rebuilding of small blood vessels, Once the treatment begins, you will sensation in their ears between such as capillaries. hear a hissing sound as the chamber treatments. This may be relieved in 7. Enhances stem cell release. pressurizes. You may also notice a the same manner as clearing your 8. Helps to clear infections in bones temporary increase in temperature ears during compression. If the and rebuild new bone. during this compression. A staff crackling should continue, please Hyperbaric Oxygen (HBO) Therapy is a member will remain with you to report this to the hyperbaric staff. medical application, which is useful in adjust the rate of compression Additionally, some patients report the treatment of selected surgical and according to your tolerance feeling light headed for a few medical problems. HBO therapy can be and coach you on relieving the moments following treatment, but used as a primary treatment modality for full sensation in your ears. The the episode is brief and the patients problems such as decompression sickness compression phase of the treatment are soon able to continue with their (the bends), or as an adjunctive therapy generally lasts about 10-15 minutes, normal daily activity. As with all to medicines and/or surgery, such as with depending upon how effective you medical procedures and treatments, skin grafts and problem wounds. are in clearing your ears. there are some side effects that HBO therapy may be administered could result from exposure to Once you are at the prescribed in either a large, steel cylinder called hyperbaric oxygen. These are rare, pressure in the chamber, your a multiplace chamber or an acrylic but they will be discussed with ear pressure sensation will go monoplace chamber. While in the you in detail before you sign your chamber you will breathe 100% oxygen away. You should feel absolutely “Consent for Treatment” form. while subject to increased atmospheric normal at this time. You may watch pressure. KEEP YOUR APPOINTMENTS: Missing your scheduled appointments can compromise the success of your ongoing care. Follow-up appointments are essential so that you and your physician can assess the progress of your treatment plan. It is also essential that you continue the prescribed plan until the treatment goals you and your physician have agreed upon have been accomplished, and until you and your physician formally agree to end your treatment. If you find you cannot keep a future appointment call the facility as soon as you can to reschedule. VISITORS: Visitors are welcome; however, children will be required to remain in the reception area. Tours may be conducted if prior arrangements have been made so we do not interfere with other patient’s treatments or their privacy. After visitors have seen the chambers they will be required to return to the reception area until your treatment is completed.

On treatment days there are several things which will need to be done before, during, and after the treatment.

BEFORE TREATMENT: Arrive thirty minutes before your scheduled treatment time. ASCENT (compressed gas is released from the chamber). You Change into approved clothing. Use the rest room and attend may get cold. Your Ears may “pop” or “crackle,” your ears will to other personal needs because there is little privacy in the equalize by themselves. DO NOT VALSALVA OR DRINK WATER ON chamber. Your physical and psychosocial condition will be ASCENT. Tell the insidestaff member immediately if the pressure assessed before treatment. Hyperbaric staff will check your does not relieve itself in your ears or sinus. Breathe normally on vital signs, as well as blood sugar if applicable. Continue ascent. DO NOT HOLD YOUR BREATHE DURING ASCENT. your regular home medications. We will review ear clearing POST TREATMENT: procedures and other information about your treatment. Drink A Hyperbaric staff member will take your vital signs after the no carbonated beverages within one hour of your treatment, treatment and monitor you for problems. You will be given as this may cause severe stomach cramps. Please tell a Wound care if ordered. hyperbaric staff member if you have any cold or flu symptoms, such as: a. Sinus drainage b. Stuffy ears or nose c. Nausea or vomiting d. Stomach cramps or diarrhea ITEMS NOT ALLOWED IN CHAMBER TREATMENT:  Synthetics, wool, silk DESCENT (compressed gas is put into the chamber). There  Oil based or petroleum products will be a hyperbaric staff member in/at the chamber with you  Lipstick, make-up, nail polish, hair spray, lotion, at all times. Inform them immediately if you require assistance. or mousses The ability to clear your ears is important in preventing ear  Hearing aides, beepers, radios, tape players, discomfort or trauma. As the chamber fills with pressure, all electronic devices, pacemakers (external), you will need to equalize the pressure inside your ears to the cell phones. pressure inside the chamber.  Non-pressurized watches, newspapers  Contact lenses (hard) There are several ways to do this: YAWN . . . SWALLOW . . .OR BLOW THROUGH YOUR NOSE WHILE PINCHING IT CLOSED Any items taken into the chamber must (VALSALVA). This is performed as follows: be approved by the technician. a. Hold your nose and close your mouth. ITEMS ALLOWED b. Blow out through your nose.  Drinking water c. Keep blowing until your ears feel normal. Tell the  100% cotton clothing staff member immediately if you cannot relieve the  One book or magazine (multiplace only) fullness or pressure in your ears.  Tissues (multiplace only) Standard treatments last about two hours. In the multiplace chamber, the oxygen hood or mask will be removed TOBACCO USE: periodically to allow you to breathe chamber air, depending If you are a smoker, you will need to stop. Nicotine on your condition. In the monoplace, you will breathe air on causes small blood vessels to constrict, and smoke/tar your breaks through an air mask. The hyperbaric staff will decreases your ability to absorb oxygen through your assess you during your treatment. Remove mask or hood only lungs. Smoking will make HBO less effective. when told. I have been made aware that possible risks and side effects of hyperbaric oxygenation include, but are not limited to:

Barotrauma: A change in ambient pressure can cause discomfort, pain, and damage to air filled spaces of the body. This can include the ears, sinuses, dental work, and lungs. I understand that HBOT inherently involves ambient pressure changes. I will be taught pressure equalizing maneuvers and that if I cannot equalize by ears, pressurization will be slowed or halted and other remedies may be applied. To prevent lung damage, which may result in air escaping into the chest cavity causing a pneumothorax or into arteries causing arterial gas embolism, pressurization and depressurization will be done slowly. Oxygen Toxicity: Oxygen is considered a medication, and as such, can have toxic effects causing seizures and/or respiratory problems at high doses. When undergoing HBOT, I am aware I will be exposed to high concentrations of oxygen. I understand that HBOT protocols are designed to prevent exposures beyond safe limits. Ophthalmic Effects: HBOT can result in various ophthalmic effects which include noticeable alterations in the structure and function of the eye. Increases in myopia (near-sightedness) are possible, and with this, decreases in presbyopia (far-sightedness). I understand that these changes usually return to normal within a few weeks, and changing corrective eyewear may be needed if significant. Worsening of established cataracts can occur from large numbers of hyperbaric oxygen treatments. These are generally well managed by eye-care professionals. Fire Risk With the presence of high concentrations of oxygen possible in and around the chamber, fire is a great risk. Policies and procedures, including guidelines for chamber occupants, have been developed to reduce fire risk. I understand that it is important for me to follow any instructions I am given pertaining to my treatment in order to maintain my safety and the safety of those around me. I have been made aware of the importance of not using any tobacco or nicotine products in the course of my treatment. These products can include, but are not limited to: cigarettes, cigars, chewing tobacco and pipe tobacco; as well as nicotine gum, patches or lozenges. I understand using tobacco or nicotine products may adversely affect the efficacy and success of hyperbaric oxygen therapy. PATIENT COPY

and WOUND CARE CONTACT INFORMATION: The staff is available to handle routine questions or concerns, Monday - Friday, 7:30 a.m. to 3:00 p.m. North Carolina Hyperbarics, LLC 3035A Boone Trail Extension Fayetteville, NC 28304 910-920-1165 Fax: 910-425-5178

NOTES:

NCH10260_180314 REV181226 HBO Cconsnet and Guide North Carolina Hyperbarics, LLC

and 3035A Boone Trail Extension WOUND CARE Your Partners In Healing Fayetteville, NC 28304 910-920-1165 Fax: 910-425-5178 PATIENT CONSENT TO HYPERBARIC OXYGEN THERAPY

Patient Name:______Date of Birth: ______Facility:

Physician: o Deon F. Faillace, MD o Florias Andrew Morfesis, MD o Helen Gelly, MD

The patient hereby acknowledges that he or she has read or had it read to them By signing below, Patient: (1) My signature below constitutes acknowledgment and agrees to the contents of this document ( hyperbaric oxygen therapy ). that I have read and agree to the attached document, and that a physician has Patient agrees that his or her medical condition has been explained to him or satisfactorily explained hyperbaric oxygen therapy to me, I have received “ A her by the physician. Patient agrees that the risks, benefits and alternatives of all Patient Guide to Hyperbaric Oxygen Therapy”, and that I have all the information care, treatment and services that patient will undergo have been discussed with that I desire. (2) I grant permission to take medical photographs of my condition patient by physician. I understand that the practice of medicine and surgery is not and hereby authorize the publishing or reproduction of such photographs for an exact science and I have been made no promises or guarantees as to the results correspondence with my referring physician and for teaching purposes. I also of hyperbaric oxygen therapy. Patient understands the nature of his or her medical understand that I will not be identified by name and that my anonymity will be condition, the risks, alternatives and benefits of treatment, and the consequences preserved in any presentation or publication. (3) consents to the transfer of health of failure to seek or delay treatment for any conditions. The patient has had the information protected by HIPAA for purposes related to treatment, payment and opportunity to ask questions of the physician and has received answers to all of health care operations. (4) Furthermore, I grant permission to take a photograph his or her questions. of myself for the purpose of patient identification. This photograph shall remain a permanent part of my patient record and will not be reproduced or published I understand that my participation in hyperbaric oxygen therapy provided by elsewhere without my consent. I understand that I am undergoing hyperbaric North Carolina Hyperbarics is voluntary and I have the right to halt treatment at oxygen treatment at my own risk. (5) I hereby give my authorization and consent any time, but I will still be held to any financial obligations per any established to the implementation of hyperbaric oxygen therapy by North Carolina payment agreements made with North Carolina Hyperbarics. Hyperbarics.

Patient understands that this consent form will be valid and remain in effect from the date of signature, as long as patient receives care, treatment and services at the facility. A new consent will be obtained when a patient is discharged from the facility and returns for care, treatment or services.

______Signature of Patient/ Parent/ Guardian or Authorized Representative Date (Guardian or Authorized Representative must attach documentation of such status.) ______Printed name of Authorized Representative Relationship / Capacity to patient

______Address and telephone number of authorized representative

The undersigned Physician has explained to the Patient (or his or her legal representative), in layman’s terms, the nature of the treatment, reasonable alternatives, benefits, risks, side effects, likelihood of achieving patient’s goals, complications and consequences which are/or may be associated with the treatment or procedure(s).

______Signature of Physician Date ORIGINAL SIGNATURE STAYS IN PATIENTS CHART NCH10260_180314 REV181226 HBO Cconsnet and Guide and WOUND CARE A Patient’s Guide to Hyperbaric Oxygen Therapy TOBACCO USE: (HBO) therapy is a medical treatment in which the entire body is exposed to increased If you are a smoker, you will need to stop. Nicotine causes small blood vessels to atmospheric pressure while the patient breathes 100% oxygen. constrict, and smoke/tar decreases your ability to absorb oxygen through your lungs. Smoking will make HBO less effective. The breathing of oxygen while in a pressurized environment stimulates the body mechanisms to promote healing. On treatment days there are several things which will need to be done before, during, and after the treatment. There is very little sensation while undergoing HBO therapy. During pressurization you will get a “fullness” buildup in your ears as a result of the pressure change. This feeling is similar BEFORE TREATMENT: to diving down to the bottom of a swimming pool, driving through the mountains or flying Arrive thirty minutes before your scheduled treatment time. Change into approved in a plane. The hyperbaric nurse will show you how to relieve this fullness so that you can clothing. Use the rest room and attend to other personal needs because there is little avoid discomfort during your treatment. privacy in the chamber. Your physical and psychosocial condition will be assessed Once the treatment begins, you will hear a hissing sound as the chamber pressurizes. before treatment. Hyperbaric staff will check your vital signs, as well as blood sugar You may also notice a temporary increase in temperature during this compression. A staff if applicable. Continue your regular home medications. We will review ear clearing member will remain with you to adjust the rate of compression according to your tolerance procedures and other information about your treatment. Drink no carbonated beverages and coach you on relieving the full sensation in your ears. The compression phase of the within one hour of your treatment, as this may cause severe stomach cramps. Please tell treatment generally lasts about 10-15 minutes, depending upon how effective you are in a hyperbaric staff member if you have any cold or flu symptoms, such as: clearing your ears. a. Sinus drainage Once you are at the prescribed pressure in the chamber, your ear pressure sensation will b. Stuffy ears or nose go away. You should feel absolutely normal at this time. You may watch television, listen to c. Nausea or vomiting music, sleep, or just rest during the remainder of the treatment, which usually lasts about d. Stomach cramps or diarrhea two hours. TREATMENT: At the end of your treatment, the pressure will gradually decrease as the chamber ascends DESCENT (compressed gas is put into the chamber). There will be a hyperbaric staff over a period of 10-15 minutes. During this decompression you will experience a popping member in/at the chamber with you at all times. Inform them immediately if you require sensation in your ears as a result of the decreasing pressure. This popping is a normal assistance. The ability to clear your ears is important in preventing ear discomfort or adjustment inside your ears. trauma. As the chamber fills with pressure, you will need to equalize the pressure inside Generally, you experience no after effects from HBO therapy. However, some patients report your ears to the pressure inside the chamber. a crackling sensation in their ears between treatments. This may be relieved in the same There are several ways to do this: YAWN . . . SWALLOW . . .OR BLOW THROUGH YOUR manner as clearing your ears during compression. If the crackling should continue, please NOSE WHILE PINCHING IT CLOSED (VALSALVA). This is performed as follows: report this to the hyperbaric staff. Additionally, some patients report feeling light headed for a few moments following treatment, but the episode is brief and the patients are soon able a. Hold your nose and close your mouth. to continue with their normal daily activity. As with all medical procedures and treatments, b. Blow out through your nose. there are some side effects that could result from exposure to hyperbaric oxygen. These c. Keep blowing until your ears feel normal. Tell the staff member are rare, but they will be discussed with you in detail before you sign your “Consent for immediately if you cannot relieve the fullness or pressure in Treatment” form. your ears. PURPOSE OF TREATMENT: Standard treatments last about two hours. In the multiplace chamber, the oxygen hood 1. A generalized constriction of blood vessels that decreases edema or swelling. or mask will be removed periodically to allow you to breathe chamber air, depending 2. Activation of the immune system to fight and kill certain bacteria. on your condition. In the monoplace, you will breathe air on your breaks through an air mask. The hyperbaric staff will assess you during your treatment. Remove mask or hood 3. Stimulation of cells to rebuild tissues and enhance healing. only when told. 4. Inactivation of toxic materials produced by bacteria. ASCENT (compressed gas is released from the chamber). You may get cold. 5. Rebuilding of small blood vessels, such as capillaries. Your Ears may “pop” or “crackle,” your ears will equalize by themselves. DO NOT VALSALVA 7. Enhances stem cell release. OR DRINK WATER ON ASCENT. Tell the insidestaff member immediately if the pressure 8. Helps to clear infections in bones and rebuild new bone. does not relieve itself in your ears or sinus. Breathe normally on ascent. DO NOT HOLD Hyperbaric Oxygen (HBO) Therapy is a medical application, which is useful in the treatment YOUR BREATHE DURING ASCENT. of selected surgical and medical problems. HBO therapy can be used as a primary treatment POST TREATMENT: modality for problems such as decompression sickness (the bends), or as an adjunctive A Hyperbaric staff member will take your vital signs after the treatment and monitor you therapy to medicines and/or surgery, such as with skin grafts and problem wounds. for problems. You will be given Wound care if ordered. HBO therapy may be administered in either a large, steel cylinder called a multiplace I have been made aware that possible risks and side effects of hyperbaric oxygenation chamber or an acrylic monoplace chamber. While in the chamber you will breathe 100% include, but are not limited to: oxygen while subject to increased atmospheric pressure. Barotrauma: KEEP YOUR APPOINTMENTS: A change in ambient pressure can cause discomfort, pain, and damage to air filled Missing your scheduled appointments can compromise the success of your ongoing care. spaces of the body. This can include the ears, sinuses, dental work, and lungs. Follow-up appointments are essential so that you and your physician can assess the progress I understand that HBOT inherently involves ambient pressure changes. I will be taught of your treatment plan. It is also essential that you continue the prescribed plan until the pressure equalizing maneuvers and that if I cannot equalize by ears, pressurization will treatment goals you and your physician have agreed upon have been accomplished, and be slowed or halted and other remedies may be applied. until you and your physician formally agree to end your treatment. If you find you cannot keep a future appointment call the facility as soon as you can to reschedule. To prevent lung damage, which may result in air escaping into the chest cavity causing a pneumothorax or into arteries causing arterial gas embolism, pressurization and VISITORS: depressurization will be done slowly. Visitors are welcome; however, children will be required to remain in the reception area. Tours may be conducted if prior arrangements have been made so we do not interfere with Oxygen Toxicity: other patient’s treatments or their privacy. After visitors have seen the chambers they will be Oxygen is considered a medication, and as such, can have toxic effects causing seizures required to return to the reception area until your treatment is completed. and/or respiratory problems at high doses. ITEMS NOT ALLOWED IN CHAMBER When undergoing HBOT, I am aware I will be exposed to high concentrations of oxygen. I understand that HBOT protocols are designed to prevent exposures beyond safe limits.  Synthetics, wool, silk Ophthalmic Effects:  Oil based or petroleum products HBOT can result in various ophthalmic effects which include noticeable alterations in the  Lipstick, make-up, nail polish, hair spray, lotion, or mousses structure and function of the eye.  Hearing aides, beepers, radios, tape players, all electronic devices, pacemakers (external), Increases in myopia (near-sightedness) are possible, and with this, decreases in cell phones. presbyopia (far-sightedness). I understand that these changes usually return to normal  Non-pressurized watches, newspapers within a few weeks, and changing corrective eyewear may be needed if significant.  Contact lenses (hard) Worsening of established cataracts can occur from large numbers of hyperbaric oxygen Any items taken into the chamber must be approved by the technician. treatments. These are generally well managed by eye-care professionals. ITEMS ALLOWED Fire Risk With the presence of high concentrations of oxygen possible in and around the  Drinking water chamber, fire is a great risk.  100% cotton clothing Policies and procedures, including guidelines for chamber occupants, have been  One book or magazine (multiplace only) developed to reduce fire risk. I understand that it is important for me to follow any  Tissues (multiplace only) instructions I am given pertaining to my treatment in order to maintain my safety and the safety of those around me. I have been made aware of the importance of not using any tobacco or nicotine products in the course of my treatment. These products can include, but are not limited to: cigarettes, cigars, chewing tobacco and pipe tobacco; as well as nicotine gum, patches or lozenges. I understand using tobacco or nicotine products may adversely affect the efficacy and success of hyperbaric oxygen therapy.