Physician Orders

This form must be completed by an MD, ND, DO, or DC licensed in California to recommend Hyperbaric Oxygen Therapy(HBOT).
By completing this form, you acknowledge the patient is physically fit to be inside a Hyperbaric Oxygen Chamber and 100% oxygen, for up to 90 minutes of treatment time, one to two times daily (4 hours apart minimum)

Doctors may call our hyperbaric adviser at Under Pressure Hyperbarics for more specific questions and concerns.

Below you can see a typical hyperbaric program based on scientific studies and research. Additional studies can be found here: https://www.ncbi.nlm.nih.gov/pubmed/

Under Pressure Hyperbarics

250 N. Robertson Blvd. Suite 104A l Beverly Hills, CA 90211 l Phone: 310-919-4179 l Fax: 818-643-4255

Patient Name

Patient DOB

Patient Gender

Biological Male Biological Female

Patient Phone

Patient has been diagnosed with the following or is being treated for general wellness

I recommend: HBOT at

ATA for total of ____ sessions

Physician Full Name

Physician Address

DEA Registration Number

Accept Below

Please review I testify that the information I have provided is true and accurate to the best of my knowledge and I have been explained the potential risks for any of the above questions that I answered “yes” to and have been given the opportunity to speak to my doctor or healthcare provider about this.

Todays Date

Practitioner Signature(Only Online Upload)