Patient Profile Patient Name DOB Gender Biological Male Biological Female Full Address Phone Emergency Contact # Emergency Contact Relationship How did you hear about us? Known Allergies? Health Concerns for Doctor to know? Currently taking medications? Yes No Medical History Pregnant or attempting to become pregnant? Cataracts Chest Surgery Claustrophobia COPD Diabetes/Low Blood Sugar Difficulty clearing ears during flight/diving Ear/Sinus Condition or Surgery Emphysema Epilepsy/Seizures Heart Disease High Blood Pressure Lung Disease Pneumothorax/Collapsed Lung Sleep apnea Referring Physician Referring Physician Phone Patient Signature(Only Online) Accept Below Please review 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 given the opportunity to speak to my doctor or healthcare provider about this. Send