Respiratory Prescription Fax to DirectHomeMedical 603-386-6277

PATIENT INFORMATION

Name David cardinal Phone 3213758967

Date of Birth 02/06/1960 Email miklotz10@gmail.com

DIAGNOSIS

 Obstructive Sleep Apnea (327.23) Length of Need (99 = Lifetime)

 Central Sleep Apnea (327.27)
Notes
 Mixed Sleep Apnea (780.57)
 COPD (496)
 Asthma (493)
 Other (Please Describe)

OXYGEN THERAPY DETAILS (Indicate Multiple Items as Needed)

 Pulse Dose (Portable) Oxygen Therapy Settings & Notes

2 LPM
 Continuous Flow Oxygen Therapy
 Supplies for the Above as Needed  Other (Please Describe)

ASTHMA & ALLERGY THERAPY DETAILS (Indicate Multiple Items as Needed)

 Compressor Nebulizer Machine Notes

 Valved Holding Chamber
 Supplies for the Above as Needed  Other (Please Describe)

SUPPLIER INFORMATION

DirectHomeMedical.com Toll Free 888-505-0212 Tax ID 80-0966280

142 Lowell Road, Suite 17-392 Fax 603-386-6277
Hudson NH 03051 Email rx@directhomemedical.com

PHYSICIAN INFORMATION

Name Dr. Alan Varraux Address 60 w Columbia st

License # ME0031947 City Orlando

Email State / ZIP 32806

Phone 407-841-1290 Fax 407-423-4406

Signature Verified by pdfFiller

Date
02/27/2024

11/28/2023