Page 7 - Norco Patient Orientation Handbook e-book

A# __________

To: Date: ________________

It has come to our attention that you have experienced, or may be at risk of a fire due to:

Smoking while using Norco oxygen services, this includes patient and people who smoke around the patient
Circle all that apply: Candles, Fireplace, Woodstove, Oven, and/or BBQ

This is a very serious concern as your personal well-being and safety are of the utmost importance to us. The
purpose of this letter is to stress how important it is to follow Norco’s well-defined safety precautions.

The Norco Patient Orientation Handbook refers to Fire Safety, and Oxygen Specific Fire Precautions. Oxygen
GREATLY enhances combustion therefore, it is critical that you observe these basic precautions. The major safety
issues are:

1. Never smoke while using home oxygen delivery system or any source of high-concentration oxygen.
2. Never allow open flames such as candles, smoking materials, BBQ, or spark-producing agents within 5 feet of
the oxygen source.
3. Also, never use the oxygen system while cooking or working with very hot surfaces
4. Electronic cigarettes should not be used while a patient is undergoing oxygen therapy. Additionally, batteries
of electronic cigarettes should not be charged in the vicinity of a patient undergoing oxygen therapy or the
oxygen source itself.

Norco’s responsibility is to make sure our patients are educated annually and comprehend the fire dangers
associated with oxygen usage. Your responsibility is to ask questions and follow these recommendations to use
your oxygen safely.

Norco will be in contact with your physician to alert him/her of reported non-compliance with safety issues. Please
always follow your physician’s guidelines to ensure your safety.

Your signature below acknowledges you have reviewed, and fully understand Norco’s oxygen safety policies and
recommendations. Your signature below also indicates you will follow the recommendations mentioned above or
specifically noted on the form and that failure to do so in the future may lead Norco to discontinue oxygen services
due to safety concerns.

Additional Recommendations:
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Patient Signature Date

Norco Representative Date