Patient Intake — Valley Health & Hyperbarics

1. Patient Information

Who is completing this form? *

I am the patient I am filling this out for someone else

Patient Information — please fill in all fields for the person being treated. Enter N/A if not applicable.

* Required fields

Today's Date *

Date of Birth *

Full Name *

Address *

City *

State *

Zip *

Phone *

Other Phone

Email *

Emergency Contact Name *

Relationship *

Emergency Phone *

2. Parent / Guardian Information

Complete if this intake is for a minor or if a guardian is involved.

Not applicable — patient is an adult with no guardian

Guardian 1

Full Name *

Date of Birth *

Relationship *

Phone *

Email *

Guardian 2 (if applicable)

Full Name

Date of Birth

Relationship

Phone

Email

3. Health History

Please be thorough. Enter "N/A" for sections that do not apply to you.

Diagnosis / Diagnoses *

Symptoms *

Current Treatment *

Allergies (Drugs/Food) *

Reaction *

3. Health History (continued)

Enter "N/A" for sections that do not apply.

Medications & Supplements (include dosage/frequency) *

Past Surgeries *

Do You Smoke? *

Yes No

Alcohol Use *

None Social Regular

Pregnant / Breastfeeding *

Yes No N/A

4. Insurance Information

Valley Health & Hyperbarics does not bill insurance for most services, but we collect this for your records.

I do not have insurance I prefer not to provide insurance information at this time

Insurance Company *

Member ID *

Group Number *

Subscriber Name *

I'll provide insurance card photos later / not right now

Insurance Card — Front

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Tap to take photo or upload

Front of insurance card

Insurance Card — Back

📷

Tap to take photo or upload

Back of insurance card

5. Services of Interest

Select all services you are interested in. This determines which consent forms you will be asked to sign.

Hyperbaric Oxygen Therapy (HBOT)

Breathing 100% oxygen in a pressurized chamber to support healing, reduce inflammation, and improve circulation.

IV Therapy

Intravenous infusion of vitamins, minerals, and hydration directly into the bloodstream.

Doctor Consultation

Meet with Dr. Benincasa-Feingold to discuss your health goals and treatment options.

6. General Treatment Consent

Please read carefully, then sign below.

Signature *

Date *

7. HBOT Informed Consent

Read the full consent. You will be asked to initial specific sections and sign at the end.

Diagnosis (for HBOT) *

Dr. Benincasa-Feingold is undertaking the following relationship with me: *

Primary Care Physician Consultant

Initial to confirm relationship selection: *

I acknowledge the side effects of HBOT have been explained to me: *

I confirm I do not have any absolute contraindications listed above: *

I acknowledge the relative contraindications have been discussed with me: *

By signing below, I consent to HBOT as described above.

Signature *

Date *

Relationship to Patient *

Witness Name

Witness Date

8. IV Therapy Informed Consent

Read the full consent. Initial specific sections and sign at the end.

Diagnosis (for IV Therapy) *

Dr. Benincasa-Feingold is undertaking the following relationship with me: *

Primary Care Physician Consultant

Initial to confirm relationship selection: *

I have informed the Physician of all allergies, medications, medical conditions, and current supplements: *

I acknowledge the risks of IV Therapy have been explained to me: *

By signing below, I consent to IV Therapy as described above.

Signature *

Date *

Relationship to Patient *

Witness Name

Witness Date

9. HIPAA & Communication Preferences

Permission to contact me regarding my care: *

Yes No

Preferred contact methods (select all that apply): *

Phone Text Email

Permission to leave a voicemail: *

Yes No

Authorized persons permitted to receive information about my care: *

Dr. Benincasa-Feingold MD abides by HIPAA Policies. We will not disclose records unless authorized by you or required by law.

10. Financial Responsibility & Payment Policy

By signing below, I acknowledge and agree to the financial policy above.

Signature *

Date *

11. Final Acknowledgment & Signature

By signing below you confirm all information provided is complete and accurate.

Print Full Name *

Signature *

Date *

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Intake Complete!

Thank you. Your completed intake packet has been sent to Valley Health & Hyperbarics. A copy has been emailed to your provider.

If you have any questions, please call us at (845) 547-2813.

Valley Health & Hyperbarics

1. Patient Information

2. Parent / Guardian Information

3. Health History

3. Health History (continued)

4. Insurance Information

5. Services of Interest

6. General Treatment Consent

7. HBOT Informed Consent

1–4. General Description, Benefits, Goals, Alternatives

5. Side Effects

6. Absolute Contraindications — I confirm I do NOT have any of the following:

Relative Contraindications — I acknowledge greater risk if I have any of the following:

8. Additional Information

8. IV Therapy Informed Consent

1. General Description

2. Benefits

3–4. Goals & Alternatives

5. Risks of IV Therapy

6. Chelation Therapy

7. Insurance & Payments

8. Additional Information

9. HIPAA & Communication Preferences

10. Financial Responsibility & Payment Policy

11. Final Acknowledgment & Signature

Intake Complete!