A Prescription (Rx) is required before O2Pod can ship to a Residential Address

Please 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:

Oxygen Concentrator LPM (Liters Per Minute) requirements/recommendations:

HBOT Usage

Recommended # Days per Week to use chamber:

Recommended Minutes per HBOT session:

Recommended Sessions per Day:

Recommended # HBOT sessions before contacting your doctor:

Prescriber Details

Name

Medical Specialty

Address

Phone Number

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 )