Referring Physicians

Provider Information

Name*

Patient Information

Name*
MM slash DD slash YYYY

Treatment Options

Why are you referring this patient? (Please select one) IHC will consult the patient, review all current labs and develop at comprehensive treatment plan. If you would like a specific procedure done please indicate the therapy and any other specifications you may have.
Desired Therapies*
Therapy Goals*

Communication

Please let us know of any concerns or possible contraindications for your patient. Please specify if patient has a history of anaphylaxis w/o IgE if requesting IV Therapy.

Required Labs

Before we can provide any High Dose Vitamin C, H2O2, Ozone/UVBI or Artusenate we must have a Quantitative G6PD (LabCorp #001917) or similar lab that has been completed within the last 60 days. Please provide other labs completed within the last 6-8 weeks. If no current labs are available,please order on behalf of your patient.
CBC*
CMP*
G6PD*

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