Online Application Step 1 of 2 50% Application for Hyperbaric Health and Wellness Veteran (HHWF) Program Participation The HHEF has 2 fundamental criteria: Participants must be a veteran/servicemember with valid DD214 or Common Access Card (CAC - valid military identification). *Note: PLEASE be ready to black out your SSN if you email a copy of these. Participants must have some official medical verification of trauma: TBI and/or PTSD. This can take many forms. It may be a VA statement of disability rating, VA medical records, or current doctor's certification of TBI/PTSD. *Note: PLEASE be ready to black out your SSN and any other Personally Identifying Information (PII) if you email a copy of these.Are you a Veteran? Yes No Veterans, please contact us for more information, and to determine qualification for our Veterans Program. Thank You Phone: 208-480-3062Do you or your veteran have a copy of your DD214 or Common Access Card (CAC)? Yes No Do you or your veteran have some form of medical verification of Traumatic Brain Injury (TBI) or Post-Traumatic Stress Disorder (PTSD)? Yes No Applicant's Name(Required) First Last Name you prefer to be called Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Applicant's Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country DISCLOSURE AND INFORMED CONSENTBy clicking YES, below you request and authorize, that you or the person whom you are a legal guardian for, be included as a patient for the use of Hyperbaric Therapy, and that a successful outcome cannot be guaranteed. I understand that the procedures and risks related to Hyperbaric Therapy to be the following: 1) I will be placed in a Hyperbaric Chamber that will be pressurized with compressed air to a pressure of up to three (3) atmospheres absolute, which is the amount of pressure used for treatment. During therapy in the Mono-place Chamber I will rest in a reclining position on a gurney that slides into the steel and acrylic chamber. I will be able to communicate with the qualified technician during my entire treatment. 2) I have been advised that while dangers are minimal, it is possible that I may experience discomfort to my ears, sinuses or teeth due to the change in barometric pressure. If such discomfort occurs, I will notify the technician, who will stop the treatment until the problem has been resolved. I understand that some individuals who experience discomfort with their ears may require a myringotomy. An ear, nose and throat specialist generally performs this as an outpatient procedure. I understand that if this procedure is required, I will miss hyperbaric treatments until the procedure is done. 3) If I have any lung abnormalities, it is possible that during decompression, I may experience problems due to the trapping of air in some part of the lungs. This may result in an arterial gas embolism, collapsed lung, or emphysema. While these problems may be serious, my physician is aware of these potential problems and does not believe that any pulmonary abnormalities exist. 4) I understand that if I am diabetic, I may be slightly more vulnerable to oxygen toxicity than a non-diabetic. However, I understand that I must eat shortly before coming for treatment and I will have a source of glucose available during treatment. 5) I understand that positive results from Hyperbaric Treatment cannot be guaranteed. I understand that as in the administration of any medication, in some instances this treatment may not have the expected or anticipated benefits. However, the desired and expected results have been explained, together with the rationale for the use of hyperbaric therapy in my particular case. 6) I understand that hyperbaric therapy is usually considered to be an adjunctive treatment and is used in conjunction with other medical treatment. Therefore, I will not discontinue my other medication and treatment of my medical condition without my doctor's specific instructions. All intravenous medication will be interrupted during the actual hyperbaric treatment, but the IV line(s) need not be removed if properly capped. 7) I understand there are risks involved in any procedure or treatment, and it is not possible to guarantee or give assurance of a successful result. 8) I understand that it is not uncommon for the eyes to undergo minor refraction during an extended series of hyperbaric treatments. I understand that this change occurs more frequently in individuals over the age of 50 than to those who are under the age of 50. I understand that these changes are usually temporary, and that after discontinuing treatment the eyes usually return to their previous condition. 9) I understand that after an extended series of treatments I may notice numbness and tingling in my fingertips. I understand this is a temporary reaction and usually disappears after hyperbaric treatments are discontinued. 10) I understand that the use of certain medications is contraindicated during treatment with hyperbaric oxygen therapy, and I agree to inform the facility personnel of all medications that I am currently taking, or have taken in the last six months. 11) I consent to the photography, filming, viewing or videotaping of the treatment of myself for educational use. 12) I am satisfied with my understanding of the nature of the procedure or treatment and all additional questions have been answered. BY CLICKING 'YES' BELOW, YOU AGREE THAT YOU HAVE READ AND UNDERSTAND THE EXPLANATIONS PROVIDED ON THIS PAGE AND VOLUNTARILY AGREE TO PARTICIPATE IN THE TREATMENT PROGRAM. (Required) Yes