New ICRFHOT Form V1 — HyOx - Hyperbaric Oxygen Therapy Clinic

Initial Consultation Referral For Hyperbaric Oxygen Therapy

Click here to fill out and sign HyoOxV1Test

Patient Legal Name

First Name

Last Name

Patient DOB:

Patient Gender

M

F

Patient Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Phone

(###)

###

####

2nd Patient Phone / Caregiver Phone

(###)

###

####

Patient Email

Primary Insurance Carrier

Primary Carrier Member ID

Secondary Insurance Carrier

Secondary Carrier Member ID

Referring Physician Name

First Name

Last Name

Referring Physician Practice Name/Location

Referring Physician Phone

(###)

###

####

Contact at Practice for patient referral communication/questions

Practice Contact Direct Phone

(###)

###

####

Practice Contact Email

Patient Diagnosis for HBO2 Therapy:

Any Prior Hyperbaric Oxygen Therapy Treatment?

Yes

No

Unknown

If yes, when/where?

Any prior radiation treatment for cancer?

Yes

No

Unknown

If yes, when/where?

Additional Information Needed Prior to Initial Consult

Initial and last two office notes
Any recent labs, cultures, imaging, and/or vascular studies
Surgical / Procedure Reports
Radiation Summary (if applicable)
Any other information relevant to a hyperbaric medicine consultation

These documents and all supporting medical records can be faxed to 678.303.3200.