Healthcare Diving Practices Statement

HEALTHCARE DIVING PRACTICES STATEMENT

Facility Name:    Location/Department:

Patient Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History and Screening

Current Medications (include dose and frequency):

Please check any of the following conditions that apply to you (check all that apply):

Diving Activity Details

Intended Diving Type:    Typical Max Depth (feet/meters):

Frequency of Dives (per year):    Last Dive Date:

Diving Risk Acknowledgment and Practices

I acknowledge that underwater diving exposes me to inherent risks including but not limited to barotrauma, decompression sickness, arterial gas embolism, drowning, and exacerbation of pre-existing medical conditions. I have reviewed and will comply with the following mandatory practices established by the facility:

• Undergo medical screening when requested by a physician prior to engaging in diving activities.
• Refrain from diving when experiencing active respiratory infection, ear/sinus congestion, uncontrolled cardiovascular symptoms, or after recent surgery as identified above.
• Avoid alcohol or sedating medications within 24 hours prior to a dive unless approved in writing by the treating physician.
• Comply with controlled ascent rates, safety stops, and no-fly/no-altitude exposure periods post-dive as instructed.
• Report any symptoms of decompression sickness or neurologic changes immediately and comply with recommended evaluation and treatment.

I certify by checking the box below that I have read the foregoing practices, understand the risks, and will follow pre-dive and post-dive medical instructions provided by the facility.

I acknowledge and agree to adhere to the facility diving practices and safety directives.

Pre-Dive and Post-Dive Instructions

Pre-dive: Avoid strenuous exercise within 12 hours of a planned dive, avoid alcohol for at least 24 hours, ensure adequate hydration, and report any illness to the dive medical officer. Post-dive: Observe a minimum surface interval before repeated dives and refrain from air travel for the recommended interval after diving unless cleared by a physician.

Specific exceptions or additional instructions (if any):

Emergency Authorization and Release for Treatment

If I am incapacitated or unable to consent at the time of an emergency related to diving, I authorize facility medical personnel to provide or arrange for emergency medical treatment, including but not limited to oxygen administration, recompression therapy referral, and transportation to an appropriate medical facility.

I understand that this statement is not a waiver of statutory rights but is a factual acknowledgement of risks, required practices, and my obligations. I agree to furnish accurate medical history and to notify the facility promptly of any changes in health status that may affect diving safety.

Privacy and HIPAA Acknowledgment

I acknowledge that the facility will maintain my medical information in accordance with applicable privacy regulations. By signing this statement I consent to the disclosure of pertinent medical information to dive operators, hyperbaric or emergency treatment facilities, and treating clinicians when necessary for my care and safety.

I acknowledge receipt of the facility's privacy notice and consent to necessary disclosures for my medical care related to diving activities.

Patient Certification

By signing below I certify that the information I have provided on this Healthcare Diving Practices Statement is complete and accurate to the best of my knowledge. I understand that omissions or false statements may place me at increased risk during diving activities and may lead to restriction or suspension of diving privileges until adequately evaluated.

I understand that I may be referred for further medical evaluation if the facility determines that additional assessment is required before I engage in diving. I accept responsibility to comply with any recommendations provided by a physician or diving medical officer.

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