Physicians Statement Form

PHYSICIAN STATEMENT IMPORTANT! THIS FORM MUST BE FILLED BY AN MD, ND, DO, NP, DO, PA, OR DC WHO IS LICENSED IN THE STATE OF TEXAS TO RECOMMEND HYPERBARIC OXYGEN THERAPY (HBOT) AND SUBMITTED ELECTRONICALLY OR PRINTED OUT AND BROUGHT WITH YOU TO YOUR APPOINTMENT, SIMPLY SEND THE DOCUMENT LINK VIA EMAIL, TEXT OR HAVE YOUR PHYSICIAN VISIT WEBSITE AND SUBMIT DIRECTLY.

Patient Name*

First NameLast Name

Patient Date Of Birth*

Date

Patient Phone Number*

Area CodePhone Number

I am willing to confirm that Mr./Mrs./Ms at above phone number is fit to be inside a Hyperbaric Chamber at specified pressure (ATA) for prescribed number of hours. In an ‘Optimal Hyperbaric Program’ patient(s) would achieve up to two hours inside the chamber for 5 days consecutively until a total of 40 hours is reached. This can be done in 60 or 120 minute sessions. Oxygen or oxygen concentrator may be used by facial mask or cannula, with flow rate of 10 lpm or 5 lpm respectively.*

YESNOOther

Prescribed Pressure (ATA)

Recommended Hours Of Treatment (Per Prescription)

Prescription Refills (Recommend 3 for one year of treatments)*

Please explain in more detail why you have recommended, approved or disapproved the use of Hyperbaric for your patient, as well as how many hours and at what ATA you recommend if any as a course of treatment?*

Physician Information

Prescribing Practitioner's Name*

First NameLast Name

Practitioner's Stamp/License/NPI #*

Email*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physician Signature *