Doctor Referral Doctor's Name * First Name Last Name Doctor's License number Email * Phone (###) ### #### Patients Name First Name Last Name Patient's DOB MM DD YYYY Patients Insurance Company & Plan Patient's Diagnosis FDA Approved Condition Post-Radiation Tissue Damage Compromised Skin Graft Necrotizing Soft Tissue Infections Osteomyelitis Crush Injury and Compartment Syndrome Sudden Sensorineural Hearing Loss I am willing to confirm that the above patient is fit to be inside a Hyperbaric Chamber and approved for HBOT sessions, consisting of 60- 120 minutes, for the prescribed amount of total treatments Please describe your hyperbaric medicine protocol * Thank you! We will have our billing company reach out to you.
