Prescription Form

Name of Patient:

Address:

Phone:

Diagnosis:

_______________________________________________________

Reasons for Equipment (circle):

Reduction of Pain

Reduce Muscle Spasms

Stimulate Soft Tissue Healing

Increase Range of Motion

Increase Functional Mobility

Decrease Edema & Inflammation

Post Surgical Stimulation

Reduce Pain Medication



The above identified equipment is medically necessary for an estimated period of time circles below:

1-3 Months

3-6 months

6-12

12 months or more

I the undersigned certify that the above equipment is medically necessary for this patient’s being. In my opinion the equipment is both reasonable and necessary in reference to accepted standards of medical practice in the treatment of this patient’s condition and is not prescribed as convenience equipment.

Name of Physician________________________________

Address________________________________________________

City/State/Zip________________________________________

Phone Number____________________________________________



______________________ PHYSICIAN SIGNATURE

______________________ Date

Fax 888-772-2117