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Form RX-001 Rev. 2026 · Longmont, CO

HBOT Prescription Request

For physicians prescribing hyperbaric oxygen therapy chambers for patient or in-clinic use. Please complete all required fields.

01

Patient Information

Required fields marked *
02

Prescribing Physician

03

Clinical Information

Indication for HBOT (check all that apply)
04

Contraindication Screening

Physician Attestation I have screened the patient for the following contraindications. Patient does not present with any condition checked below (or condition has been addressed and documented).
05

Prescribed Treatment Protocol

06

Physician Attestation & Signature

Physician Signature (Typed)
Date
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