Immersion Therapy Medical Certificate

Date *

Dear Doctor,

Your patient is interested in undertaking Immersion Therapy (IT). Immersion Therapy is water-based intervention with the additional use of Self Contained Underwater Breathing Apparatus (SCUBA) to allow total body immersion.

The IT program is specifically designed to be inclusive, safe, and is delivered by appropriately trained and registered Allied Health Professionals.

The breathing of compressed air via SCUBA even under supervision in a controlled environment at relatively shallow depth requires medical consideration.

The medical standards for Immersion Therapy are different from those required for using SCUBA in Open Water or recreational SCUBA Diving. The medical standards for IT have been considered by experts in Diving Medicine and Rehabilitation Medicine who have developed this certificate.

The following medical conditions present a higher level of risk and should be referred to a specialist doctor with qualifications in underwater medicine.

Prior pneumothorax
Prior surgery through the pleural cavity
Asthma requiring regular bronchodilator use or triggered by water or exercise
Obstructive pulmonary disease, emphysema, bronchiectasis
Unstable Diabetes
Uncontrolled epilepsy
Perforated ear drum
Pregnancy
Active infection

If your patient does not have any of the above conditions, would you please confirm this by completing the attached certificate.

If you are uncertain about your patient’s medical capacity to undertake IT and want them to seek advice from a Medical Practitioner accredited in Diving Medicine, then please indicate this on the certificate.

For further information on Immersion Therapy please view here

Immersion Therapy (partnersinhealth.com.au)

Reason for completing this form today *

I am referring my patient and completing the health assessmentI am only completing the health assessment

Patients First Name *

Patients Last Name *

Patients Email Address *

Patients Phone Number *

Patients Date of Birth *

Doctors Full Name *

Doctors Provider Number *

Doctors Phone Number *

Doctor's Email *

If any of the conditions above have been identified please upload a medical history, with additional information about the identified condition if possible.

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Additional information or comments

Are there any contraindications to general exercise *

YesNo

Patient is *

Suitable for Immersion TherapyRequires referral to specialist doctor with qualifications in underwater medicineNot Suitable for Immersion Therapy

This certificate is valid for 12 months from date of assesment unless otherwise stated

This document certifies that

Is

This certificate is not valid for any other purpose and expires on 12 months from date of assessment. For the avoidance of doubt, the certificate DOES NOT certify fitness to participate in Open Water Diving, or in any use of SCUBA equipment outside of the authorised application of Immersion Therapy. The certificate is to be used in conjunction with the approved Policies and Procedures of Immersion Therapy and the participant must comply with those Policies and Procedures, and with the instructions of authorised Immersion Therapy providers

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