Bethesda Hyperbaric Oxygen Therapy

New Patient Inquiry - Secure Web Form

By completing this form you are simply providing information that will assist us in responding to your interests in Hyperbaric Oxygen Therapy, and how we may be of service to you.

Your details

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      1. How do you prefer to communicate?
      1. When should we call you ?

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    Where you referred by a Physician or Health Care Provider ? YesNo

    Name of Physcian or Health Care Provider who referred you.



Please Answer the Following Questions

How do you think we can help you?

Please enter a short description of the condition for which you need help.

What other conditions have you been told that you have? List diagnoses.

If you have had a concussion, please describe the dates and circumstances.

In the past two years, approximately how many practitioners have you seen for medical help?

What kind of information do you need regarding hyperbaric oxygen therapy?

Do you have difficulty with comprehension or memory after reading or conversation?
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    1. YesNo

    2. YesNo

    1. YesNo

    2. YesNo




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Thank you for your interest in Hyperbaric Oxygen Therapy. We will respond to your inquiry promptly.

By pressing the SUBMIT button below, I certify that I am the person identified on this form, or that I am the legal guardian of the person named on this form, or I am completing this form on behalf of an individual who is not capable of completing this form. I also certify that these answers are true to the best of my knowledge.

Quick Contact Form

For more information or to request an appointment, please complete the following information.

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We will respond during normal working hours, Mon.-Thurs. between 9am and 5pm; and Friday between 9am and 1pm.

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