Client oxygen prescription

This form to be completed by client
Oxygen prescription

Dispense only as written

Contact 833-360-2155 | Fax 800-418-6998 | www.oxygenparts.com
Client information
Client name

First NameLast Name
Client phone number or responsible party
Please enter a valid phone number.Format: (000) 000-0000.
Client email or responsible party
example@example.com
Client date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of person submitting prescription:

First NameLast Name
Phone number of person submitting prescription
Please enter a valid phone number.Format: (000) 000-0000.
Email of person submitting prescription
example@example.com
Client address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescription
Portable oxygen concentrators (POCs) have the ability to provide flow up to 9 setting on pulse dose (on demand while breathing through nose).
- Smaller POC pulse settings are from 1–6 pulse only
- Larger POCs have the ability to produce .5 to 3 LPM continuous flow and provide pulse setting up to 6 settings.
Various models produce different flow settings depending on size and make.
- Standard stationary oxygen concnetrators have a flow setting from 1–5 LPM continuous.
- High flow stationary concentrators have flow settings from 2–10 LPM continiuous flow.
Liter per minute (LPM)
Enter in the Prescribed Liter Per Minute
Prescribed oxygen usage (Continuous flow recommended for sleep)
Date prescription submitted

MonthDayYear
2 digit month, 2 digit day, 4 digit yearToday's Date
Client signature
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Oxygen prescription

Client information

Prescription