Recommendation Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Practitioner InformationRecommending Practitioner *Business Name *Practitioner Phone *Business Email *Name of Staff Member *Patient InformationPatient Name *FirstLastPatient Phone *If registering a child, please provide the parent or guardian's phone number.Patient Email Address *If registering a child, please provide the parent or guardian's email address.What Conditions Are You Recommending Echo Hydrogen Water For? What Conditions Are You Recommending Echo Hydrogen Water For? Cardiovascular DiseasesCardiovascular DiseasesHeart disease, stroke, hypertension, heart failure, atrial fibrillationCancerCancerLung cancer, breast cancer, prostate cancer, colorectal cancer, skin cancerRespiratory DiseasesRespiratory DiseasesChronic obstructive pulmonary disease (COPD), asthma, pneumoniaNeurological DisordersNeurological DisordersAlzheimer's disease, Parkinson's disease, multiple sclerosis, epilepsyDiabetes and EndocrineDiabetes and EndocrineType 1 diabetes, type 2 diabetes, thyroid disorders, osteoporosisMental HealthMental HealthDepression, anxiety, bipolar disorder, schizophrenia, PTSD, ADHDSubstance Abuse/AddictionSubstance Abuse/AddictionAlcohol use disorder, opioid use disorder, tobacco addictionInfectious DiseasesInfectious DiseasesInfluenza, COVID-19, HIV/AIDS, hepatitis C, Lyme diseaseKidney and Urinary DisordersKidney and Urinary DisordersChronic kidney disease, kidney stones, urinary incontinence, UTIsDigestive DisordersDigestive DisordersGastroesophageal reflux disease (GERD), Crohn's disease, IBS, ulcerative colitisMusculoskeletal Disorders Musculoskeletal Disorders Arthritis, osteoarthritis, rheumatoid arthritis, gout, fibromyalgiaObesity and Weight-RelatedObesity and Weight-RelatedObesity, overweight, metabolic syndrome, eating disordersEye and Vision DisordersEye and Vision Disorders Age-related macular degeneration, cataracts, glaucoma, diabetic retinopathyHearing DisordersHearing DisordersHearing loss, tinnitus, Meniere's disease, ear infections, Presbycusis, Mixed Hearing Loss, etc.Reproductive HealthReproductive HealthInfertility, endometriosis, polycystic ovary syndrome, uterine fibroidsSkin DisordersSkin DisordersAcne, eczema, psoriasis, rosacea, skin cancerOther Condition Please Describe:HIPAA Consent *Patient has provided consent to share contact information with Echo Technologies LLCPatient has verbally authorized to: Share my protected health information (PHI) with Echo Technologies LLC for the purpose of consulting with me regarding their products and services in compliance with the Health Insurance Portability and Accountability Act (HIPAA). I also authorize Echo Technologies LLC to Leave messages containing limited PHI on my voicemail, email, or text messages. I understand that: I may revoke this consent in writing at any time, except to the extent that the physician listed on this form or Echo Technologies LLC has already acted upon my previous consent. My PHI may be disclosed by the healthcare providers receiving my information and may no longer be protected by the federal privacy regulations. This consent is voluntary, and I may refuse to sign it without affecting my right to obtain treatment or payment, enroll or be eligible for benefits, or participate in healthcare operations. Submit
