We work collaboratively with ENT specialists in the GTA to triage Hyperbaric Oxygen Therapy for ISSHL Patients

Once consulted we will aim to get the patient seen within 24 hours and treatment started within 72hrs

    PATIENT INFORMATION

    DATE OF BIRTH

    GENDER

    REASON FOR REFERRAL

    MEDICAL INFORMATION







    ADDITIONAL ATTACHMENTS

    PLEASE ATTACH THE FOLLWING REPORTS, IF AVAILABLE:

    CHEST X-RAY, ECG, PFT’s, ECHOCARDIOGRAM, CHEST CT, PAST MEDICAL HISTORY, CURRENT MEDICATION LIST, BLOODWORK INCLUDING CBC, UREA, CREATININE, ELECTROLYTES, CRP, ESR, HbA1c, CARDIOLOGY, RESP, ENT, VASCULAR SURGERY, ABI RESULTS, AUDIOLOGY REPORTS (FOR ISSNHL), SPIROMETRY, WOUND CULTURES. PLEASE ONLY SUBMIT WORD OR PDF FILES.

    REFERRER'S INFORMATION

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