A Prescription (Rx) is required before O2Pod can ship to a Residential AddressPlease complete the information below. Upon receipt, we will process your order. Patient Details Patient Name (full name) Patient Street Address City State Zip Patient Email Patient Phone Prescription Details Date Prescription was Written Does Prescription specify Hyperbaric Oxygen Therapy? Yes No (ask prescriber to specify HBOT) ATA (Atmospheres Absolute) Pressure in Chamber requirements/recommendations: Not Specified1.3 ATA1.4 ATA1.5 ATA1.3 - 1.5 ATA>1.5 ATA Oxygen Concentrator LPM (Liters Per Minute) requirements/recommendations: Not Specified5101520Any HBOT Usage Recommended # Days per Week to use chamber: Not Specified4575-7 Recommended Minutes per HBOT session: Not Specified456080-9090-120other Recommended Sessions per Day: Not Specified121 or 23 or more Recommended # HBOT sessions before contacting your doctor: Not Specified406090120 Prescriber Details Name Medical Specialty Choose OneMedical Physician (MD)Osteopathic Physician (DO)Chiropractic Physician (DC)Dentist (DMD or DDS)Nurse Practitioner (NP, ARNP)Veterinarian (DVM)Licensed Naturopath (ND) - must be in AZ, HI, MO, NH, OR, UT, VT, WA Address Phone Number Email DEA Number (format = 9 or 9+5 characters) Signature Prescription File Upload an image of your written prescription file ( jpg, png, gif, pdf | 5 MB Max ) Upload Your Prescription (Rx)