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 patients being. In my opinion the equipment is both reasonable and necessary in reference to accepted standards of medical practice in the treatment of this patients condition and is not prescribed as convenience equipment.
Name of Physician________________________________
Address________________________________________________
City/State/Zip________________________________________
Phone Number____________________________________________
______________________ PHYSICIAN SIGNATURE
______________________ Date
Fax 888-772-2117