Kare Center

Physician Referral Form

THIS FORM MUST BE FILLED BY AN MD, DO, NP, OR PA WHO IS LICENSED TO RECOMMEND HYPERBARIC OXYGEN THERAPY (HBOT) AND SUBMITTED ELECTRONICALLY OR PRINTED OUT AND BROUGHT WITH YOU TO YOUR APPOINTMENT, SIMPLY SEND THE DOCUMENT LINK VIA EMAIL, TEXT OR HAVE YOUR PHYSICIAN VISIT WEBSITE AND SUBMIT DIRECTLY.


    I am willing to confirm that Mr./Mrs./Ms at above phone number is fit to be inside a Hyperbaric Chamber at specified pressure (ATA) for prescribed number of hours. In an ‘Optimal Hyperbaric Program’ patient(s) would achieve up to two hours inside the chamber for 5 days consecutively until a total of 40 hours is reached. This can be done in 60 or 120 minute sessions. Oxygen or oxygen concentrator may be used by facial mask or cannula, with flow rate of 10 lpm or 5 lpm respectively. *


    Prescribed Pressure (ATA) *

    Recommended Hours Of Treatment (Per Prescription)

    Prescription Refills (Recommend 3 for one year of treatments)


    Please explain in more detail why you have recommended, approved or disapproved the use of Hyperbaric for your patient, as well as how many hours and at what ATA you recommend if any as a course of treatment?

    Physician Information

    Address