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HBOT Contact Form
HBOT Contact Form
Please fill out the following questions. All responses are kept strictly confidential in accordance with our privacy policy and HIPAA data regulations.  
HBOT Contact Form - Ontario HBOT (2021)
Language
  • English (US)
  • 1
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  • 2
    Mobile Preferred
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  • 3
    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.
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  • 4
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  • 5
    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.
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  • 6
    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
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  • 7
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  • 8
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  • 9
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  • 10
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  • 11
    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.
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  • 12
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  • 13
    All 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
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  • 14
    Click on the "take photo" button below, and your device's camera will activate and attach the photo to the form
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  • 15
    Please be as detailed as possible
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  • 16
    This helps us secure your preferred spot during the intake process in priority sequence
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  • 17
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