Doctor ReferralPDF Link 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 Soft Tissue Radiation Necrosis Radiation Cystitis Radiation Proctitis (*not Medicare) Osteo Radiation Necrosis Pre and Post Dental Extractions for a Radiated of Mandible Chronic Osteomyelitis Compromised Skin Graft / Flap Diabetic Foot Ulcer Crush Injury and Compartment Syndrome Sudden Sensorineural Hearing Loss (*not Medicare) Avasculur Necrosis (Osteonecrosis) * only Cigna and United Healthcare cover 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.
