I certify that the above treatment plan is medically necessary and the services prescribed are approved by me.

PLEASE ATTACH ALL RELEVANT MEDICAL NOTES AND MEDICAL HISTORY o Current History and Physical (completed within 30 days of evaluation)o List of Current Medications, Dressings, Wound Care, etc.o Recent Lab Results, Radiology Reports, EKG, Vascular Studies, Implantable Devices

Refractory Osteomyelitis Compromised Flap/Tissue/Ortho. Device Radiation Damage/Bone/Skin/Cystitis/Proctitis Post Op Wound Infection Non-Healing Surgical Wound (30+ Days) Sensorineural Hearing Loss Burns (second and third degree) Retinal Artery Occlusion

Trauma Wound/Crush Injury Diabetic Wound/Ulcer Necrotizing Soft Tissue Infection Lower Extremity Ulcer (arterial/venous) Brown Recluse Spider Bite Perianal Skin Complications (IBD) Pre/Post Dental Surgery on Radiated Jaw Intracranial abscess

EVALUATE AND TREAT: Check All That Apply

Wound Care Management Hyperbaric Evaluation

================================== PATIENT INFORMATION =================================

First Name _______________________________________________ Last Name _________________________________________

P 210.582.5304

F 210.582.5307

www.R3Healing.com

Phone Number ________________________________________ Insurance ____________________________________________

============================== REFERRING CLINIC INFORMATION =============================

Referred by_______________________________________________________________Date_________________________________

Authorized Signature___________________________________Office Phone___________________________________

================================ ADDITIONAL INFORMATION ===============================

ARTERIAL INSUFFICIENCY PVD NEUROPATHY DIABETES SMOKER MALNUTRITION

IMMUNOSUPPRESIVE THERAPY CONNECTIVE TISSUE D/O

_____________________________________________________________________________________________________________________________________________________________________________________________

FOR YOUR VISIT, please:

P210.582.5304�F 210.582.5307�www.R3Healing.com

San Antonio - Medical Center9150 Huebner RdSuite 120San Antonio, TX 78240

San Antonio - Stone Oak18626 Hardy Oak BlvdSuite 103Suite 103San Antonio, TX 78258