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Fax Oxygen Prescription RANA Respiratory Care Group  Form

Fax Oxygen Prescription RANA Respiratory Care Group Form

Use a oxygen prescription form 0 template to make your document workflow more streamlined.

Patient s home at no cost after 30 days. Damage caused by misuse or smoke will be charged to the patient for repair and cleaning Referring Physician Authorization Please Print Information or Affix Clinic Label Name Clinic Name Phone Address Patient Name Birth Date / / Health Services Number R Oxygen Therapy LPM for hours/day Maintain SpO2 at Additional Notes Physician Signature Date / / Physician Name Print Doctor Prescriber Number Confidentiality Note Property of RANA Respiratory Care Group....
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