Client Intake - Regen Hyperbaric Oxygen Therapy

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Client Information

Name *

First

Last

Date of Birth *

Gender *

Phone *

Email *

Address *

Address Line 1

City

State

Zip Code

Emergancy Contact

Emergency Contact Name *

Emergency Contact Phone *

Relationship to the Client

Medical History

Please select all that apply.

Do you have any of the following conditions? *

Asthma or COPD
Emphysema
Pneumothorax (Collapsed Lung)
Recent Cold or Congestion
Chest Surgery
Congestive Heart Failure or Cardiac History
Uncontrolled High Blood Pressure
Claustrophobia
Epilepsy/Seizures
Diabetes
Pregnancy
History of Ear Surgery or Tubes
Sinus/Ear Pain or Pressure Problems
Cancer / Chemotherapy (past or current)
None of the Above

Do you have any other medical conditions? *

If yes, please provide details

Any other disabilities or conditions not mentioned above? *

If yes, please provide details

Current Medications and Supplements

Please list all prescription medications, over-the-counter drugs, vitamins, supplements, and recreational substances

Are you currently taking any medications, herbs or substances? *

any when you

If yes, please list here:

Surgical History

Have you had any recent surgeries? *

Please include elective procedures (such as breast augmentation/ tummy tuck/ BBL/ facelift) so we can have the chamber appropriately ready to maximize your comfort level.

If yes, please provide details

Do you have implanted devices (e.g., pacemaker, cochlear implant, insulin pump)? *

If yes, please provide details

HBOT Screening Questions

Are you experiencing any cold, allergy, sinus, or respiratory symptoms today? *

Yes
No

Do you have any difficulty equalizing ear pressure (e.g., when flying)? *

Yes
No

As in, you were unable to equalize/clear your ears, which caused discomfort

Do you experience anxiety or claustrophobia in enclosed spaces? *

Yes
No

Have you ever undergone HBOT before? *

Yes
No

Were you refered by someone or doctor's office?

Please share who referred you.

Cold & Respiratory Symptoms (CLIENTS)

Severe respiratory symptoms (Pneumonia/Flu/COVID/Asthma) are contraindications to HBOT. You may resume when symptoms improve.

For Cold/Viral Symptoms: *

Please describe in detail any symptoms you are currently experiencing that may be associated with a cold or viral illness, including their onset, duration, and severity.

Cold & Respiratory Symptoms (GUESTS)

You are welcome to bring people with you to your appointment, but they must be symptom-free. For guests with mild symptoms, masks are required. Please be mindful that we also care for immunocompromised patients with weakened immune systems.

Consent for Hyperbaric Oxygen Therapy

Please review the following documents:

Hyperbaric Oxygen Therapy FAQ, Risk Factors, and Consent

Cancellation and Refund Policy

Liability Waiver

Consent for Treatment *

I acknowledge and accept the terms outlined in the Hyperbaric Oxygen Therapy FAQ, Risk Factors, and Consent.

Cancellation and Refund Policy *

I acknowledge and accept the terms outlined to the Cancellation and Refund Policy.

Liability Waiver *

I acknowledge and accept the terms in the Liability Waiver and risks, terms, and limitations of the services provided.

Confirmation

I testify that the information I have provided is true and accurate to the best of my knowledge, and I have been explained the potential risks for any of the above questions that I answered “yes” to, and have been allowed to speak to my doctor or a healthcare provider about this. I hereby consent and authorize Althea Integrative Wellness LLC and its trained HBOT technicians to administer hyperbaric oxygen therapy (HBOT) to me.

Client Name *

Today's Date *

(If under 18) Parent/Guardian Name

Provide Parent/Guardian signature below:

Signature *

Clear Signature

Contact

Call/Text (818) 669-6960

info@regenhyperbaric.com

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Office Location

4403 Riverside Dr. Ste A

Chino, CA 91710

Office Hours

By Appointment Only

Monday to Friday 5 AM – 8 PM

Saturday 5 AM – 3 PM

Sunday Closed

© 2026 Regen Hyperbaric LLC. All rights reserved.

Health Disclaimer: These statements have not been evaluated by the Food and Drug Administration. This service is not intended to diagnose, treat, cure, or prevent any disease. It is essential to consult with a qualified healthcare professional for any health concerns or before making any decisions related to your health or treatment.