HBOT Contact Form - Ontario HBOT (2021)

1
Full Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.Mobile Preferred
Area Code
Phone Number
3
Text Communication Consent* This field is required.Would you like to give consent for the Care Team at Ontario HBOT to communicate with you about your care via text message? For example: making, changing and/or cancelling appointments.
YESNO
4
Email* This field is required.
example@example.com
Confirm Email
5
Email Communication Consent* This field is required.Would you like to give consent for the Care Team at Ontario HBOT to communicate with you about your care via e-mail message? For example: making, changing and/or cancelling appointments.
YESNO
6
Which of the following conditions are you seeking treatment for?* This field is required.If you do not see your specific condition, please choose "other"
Please select one of the following
Please select one of the following
Air or Gas Embolism
Carbon Monoxide (CO) Poisoning
Cerebral Palsy (CP)
Chronic Anemia
Chronic Non-Healing Wound
Compromised Skin Graft & Flap
Crush Injury & Compartment Syndrome
Decompression Sickness "The Bends"
Delayed Radiation Injury
Fibromyalgia/Nerve Pain
Gas Gangrene (Clostridial Myonecrosis)
Idiopathic Sudden Sensorineural Hearing Loss (ISSHL)
Insomnia
Intracranial Abscess (Brain Infections)
Lyme Disease
General Wellness/General Health
Multiple Sclerosis (MS)
Necrotizing Soft Tissue Infections
Osteomyelitis (Bone Infection)
Parkinson's Disease
Pre/Post Plastic Surgery
Post-Concussion Syndrome (PCS)
Post Motor Vehicle Accident (MVA)
Soft-Tissue Injury
Thermal Burns
Tinnitus
OTHER
7
Please describe your condition
8
Do you currently have any issues with your lungs?* This field is required.
YESNO
9
Do you have any issues with your heart?* This field is required.
YESNO
10
Do you have any medical documentation?* This field is required.
YESNO
11
Would you like to securely send your documentation to us for review?* This field is required.Medical documentation is sent via a secure HIPAA compliant pipeline directly to our servers. For more information, please visit our website to view our privacy policy, or ask a care team member for further details on how your data is handled.
YESNO
12
How would you prefer to provide the results?
Upload the document from your device
Write a brief description of your own
Active your device camera and take a picture (Mobile or Tablet ONLY)
13
Browse for the file or draw and drop to uploadAll files are sent securely with the form results to our Care Team
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Chest X-Ray
Cancelof
14
Take PhotoClick on the "take photo" button below, and your device's camera will activate and attach the photo to the form
15
Summarize what is described in your medical documentationPlease be as detailed as possible
Huge
Large
Normal
Small
Ok
Ok
16
Please specify when you would prefer to start your treatments. PLEASE NOTE: THIS IS NOT A CONFIRMED APPOINTMENT* This field is required.This helps us secure your preferred spot during the intake process in priority sequence
17
Please verify that you are human* This field is required.
Should be Empty:

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