Physician Referral

Patient Name

DOB

Phone

DIAGNOSIS

ICD-10 Code Actinomycosis Acute Carbon Monoxide Poisoning Acute Peripheral Arterial Insufficiency Acute Traumatic Peripheral ischemia Chronic Refractory Osteomyelitis Compromised Skin Graft/Flap Crush injury Decompression Illness Diabetic Wound(s) of Lower Extremity Enhancement of Healing in Selected Problem Wounds Exceptional Blood Loss Anemia Gas Gangrene Intracranial Abscess Late Effect Radiation Necrotizing Fasciitis Osteoradionecrosis Preparation for Flap/Graft Radiation Necrosis Soft Tissue Radionecrosis Thermal Burns Other

Notes

Referring Physician

Referring Physician Phone

PLEASE ATTACH Physician Signature, Demographics and Last Progress Note

Accept Below

I accept to pass information to Under Pressure Hyperbarics 250 N. Robertson Blvd., Suite 104A Beverly Hills, CA 90211 Phone: 310-919-4179 l Fax: 818-643-4255

Send