If you are interested in receiving mild Hyperbaric Oxygen Therapy at our center, please fill out and submit the following form. Someone from our center will contact you as soon as possible. Please be patient, we get very busy at times but please don’t let this stop you from contacting us.

First Name of Child

Last Name of Child

Name of Person completing this form

Your Relationship to Child

Email

What type of email is this?
–None– Personal Work Alternate

Best Phone Number

What Type of Number is This?
–None– Home Work Mobile Other

Address

City

State/Province

Zip/Postal Code

Country

How did you hear about us?

Please give a summary of the child’s medical condition and history. Be sure to list diagnosis, any doctors seen and their recommendations, symptoms, medications, date of onset and any other important information.

What are you hoping will happen with mild Hyperbaric Oxygen Therapy?

Will you need assistance getting the child in and out of the chamber? Please give specifics.

Please describe the child’s current social / family situation – school, what family members he spends his time with, who cares for him, etc.

Please let us know what your living arrangements will be if/when you arrive. Do you live close enough to drive daily? Do you have friends or family you will stay with? Do you need assistance finding living arrangements?

Are you interested in making a donation to the center? Donations are not required, but do help us continue to provide services free of charge.

Are you interested in volunteering for the center either at the center or from home?:

Do you know people or businesses who would be interested in donating or volunteering?

We try to accommodate everyone’s schedules, so please let us know if there is a time of day you would prefer to be scheduled. This is not guaranteed, but we will do our best.