Physician’s Prescription

Patient Name:

Patient Email

Date of Birth:

Prescription Date:

Address:

Phone:

Physician's Prescription:

Purchase of or use of a mild Hyperbaric Oxygen Chamber at 1.3 ATA with oxygen concentrator, 60-90 minute treatments, titrate duration and frequency of treatments as needed for

Primary Diagnosis:

Secondary Diagnosis:

Referring Physician:

Physician's Address:

Email:

Phone/Fax:

DEA:
State, License #:

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