Prescription Form

Name of Patient:





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


12 months or more

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

Name of Physician________________________________



Phone Number____________________________________________

______________________ PHYSICIAN SIGNATURE

______________________ Date

Fax 888-772-2117

Prescription Form

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