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 #: All fields are required