Patient Referral Form for Hyperbaric Oxygen Therapy (HBOT)

To be submitted by the referring physician to HWC.

Date of Referal

Patient's Name

Patient's Phone

Date of birh

Does this patient have hypertension?

No

Yes

Does this patient have diabetes mellitus?

No

Yes

PRESCRIPTION and ICD-10 CODES ARE REQUIRED FOR THIS PATIENT:

PATIENT'S DIAGNOSIS(ES)

Diabetic non-healing wound

Soft Tissue radionecrotic

Osteoradionecrosis

Chronic refractory osteomyelitis

Progressive necrotizing infections

Sudden or acoustic hearing loss

PATIENT'S CLEARANCE FOR HYPERBARIC OXYGEN THERAPY BY PROVIDER:

Patient's ears are clear

Patient's chest is clear

Patient does not have Pneumothorax or known lunng issue

Patient does not have a known contraindication of HBOT

Patient is approved for HBOT per protocol:

REFERRING PHYSCIAN'S SIGNATURE

PRINT PROVIDER'S NAME

NPI#

PHONE NUMBER

EMAIL

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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