If you would like to submit a referral we need the following information:

1. Basic Patient Information (or fax face sheet 315.339.4134)

  • Name
  • Address & phone number
  • Insurance information
  • Diagnosis
  • Height and Weight

2. Type of Equipment

3. When Ordering Oxygen:

  • Sat % or ABG
  • Date Sat % of ABG was performed

4. Name of the Ordering Physician

5. Discharge Information

  • Date
  • Time
  • Room Number if Applicable

You are more than welcome to use your own form/face sheet etc. or you may use ours. Simply click here or find it under the "Rentals/Services" tablabeled "Intake/Referral".