Physician Form

Patient Name

Date of Birth

BASED ON MY ASSESSMENT, (PROVIDER MUST CHECK 1 OF THE 3 BOXES BELOW): BASED ON MY ASSESSMENT, (PROVIDER MUST CHECK 1 OF THE 3 BOXES BELOW): My patient is cleared and approved to use Mild Hyperbaric Oxygen Therapy for general health and wellness for 60 minutes per day at hyperbaric pressures at or below 2.0 ATA. My patient has been diagnosed with a condition as stated below and I recommend: HBOT at 1.3 ATA for 55 minutes for a total of sessions, or as recommended by your hyperbaric oxygen therapist. I do not recommend the use of Mild Hyperbaric Oxygen Therapy for reasons stated below

Condition diagnosed:

Recommended Sessions:

Reasons listed:

Additional Comments:

Physician/Practitioner Name

Physician/Practitioner Phone

Date Signed

Physician/Practitioner Signature SaveClear