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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 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________________________________

Address________________________________________________

City/State/Zip________________________________________

Phone Number____________________________________________



______________________ PHYSICIAN SIGNATURE

______________________ Date

Fax 888-772-2117

Prescription Form
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Why Buy from LGMedSupply?

Our customers are our most important asset!

  • Very happy with responsiveness from customer service in answering questions. Happy with value of purchase.

    - Written on February 6, 2016
    Star Rating for Our CCTV

  • My entire transaction with LGMedSupply was SUPER EASY and FLAWLESS!!!!! The products are TOP QUALITY and my package arrived fast and with NO DAMAGE! Thank You, LGMedSupply!

    - Written on January 12, 2016
    Star Rating for Our CCTV

  • Very professional, courteous, and willing to work with you. Have used this company for many years, and have never been dissatisfied with their products or service.

    - Written on January 27, 2016
    Star Rating for Our CCTV

  • My order arrived not only on time but before promised! It was also correct.

    - Written on January 22, 2016
    Star Rating for Our CCTV

  • Item was a great value. Guarantee exceeds those from competitors. Item shipped same day. Arrived earlier than expected.

    - Written on January 17, 2016
    Star Rating for Our CCTV

  • I have been very pleased with both orders. On time and very good product.

    - Written on January 31, 2016
    Star Rating for Our CCTV

  • Excellent, friendly service and very quick delivery.

    - Written on January 31, 2016
    Star Rating for Our CCTV

  • My purchase arrived the very next day!

    - Written on January 30, 2016
    Star Rating for Our CCTV

  • Every time I have ordered from LG they have been great. Orders are always correct and always on time. Perfect!! Thanks. LG

    - Written on January 6, 2016
    Star Rating for Our CCTV

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