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Recommendation Form

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Practitioner Information

Patient Information

Patient Name
If registering a child, please provide the parent or guardian's phone number.
If registering a child, please provide the parent or guardian's email address.

What Conditions Are You Recommending Echo Hydrogen Water For?

Cardiovascular Diseases
Heart disease, stroke, hypertension, heart failure, atrial fibrillation
Lung cancer, breast cancer, prostate cancer, colorectal cancer, skin cancer
Respiratory Diseases
Chronic obstructive pulmonary disease (COPD), asthma, pneumonia
Neurological Disorders
Alzheimer's disease, Parkinson's disease, multiple sclerosis, epilepsy
Diabetes and Endocrine
Type 1 diabetes, type 2 diabetes, thyroid disorders, osteoporosis
Mental Health
Depression, anxiety, bipolar disorder, schizophrenia, PTSD, ADHD
Substance Abuse/Addiction
Alcohol use disorder, opioid use disorder, tobacco addiction
Infectious Diseases
Influenza, COVID-19, HIV/AIDS, hepatitis C, Lyme disease
Kidney and Urinary Disorders
Chronic kidney disease, kidney stones, urinary incontinence, UTIs
Digestive Disorders
Gastroesophageal reflux disease (GERD), Crohn's disease, IBS, ulcerative colitis
Musculoskeletal Disorders
Arthritis, osteoarthritis, rheumatoid arthritis, gout, fibromyalgia
Obesity and Weight-Related
Obesity, overweight, metabolic syndrome, eating disorders
Eye and Vision Disorders
Age-related macular degeneration, cataracts, glaucoma, diabetic retinopathy
Hearing Disorders
Hearing loss, tinnitus, Meniere's disease, ear infections, Presbycusis, Mixed Hearing Loss, etc.
Reproductive Health
Infertility, endometriosis, polycystic ovary syndrome, uterine fibroids
Skin Disorders
Acne, eczema, psoriasis, rosacea, skin cancer
HIPAA Consent
Patient 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.