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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