Referring Physicians

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Provider Information


Patient Information

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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*


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.

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