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Letter of Necessity Form

Letter of Necessity Form
First Name: ________________________________________
Last Name: ________________________________________
Date of Birth: ______________
Clinic Name: _______________________________________
Clinic Phone Number: _______________________________
Patient Information:
Electrical Stimulation Units (check the unit being prescribed):
____ TENS Unit
____ TENS/EMS Combo Unit
____ Interferential Unit
____ Galvanic Unit
____ Microcurrent Unit
____ Cervical Traction
____ Lumbar Traction
Medical Necessity (check treatment goal):
____ Relax muscle spasms
____ Pain Control
____ Re-educate muscles
____ Retard disuse atrophy/muscle weakness
Length of Use: _______________________________________
Physician Signature x________________________________ (Includes Medical Doctors, Chiropractors, Dentists, Podiatrists, Nurse Practitioners, Physicians Assistants, Ph.D., Physical Therapists, Doctor of Acupuncture or Doctor of Osteopathy)
Phone Number: _______________________________________
Fax Number: _________________________________________
Date ________________________________________________
I the above signed, confirm the order for the above-named patient. I also certify that the prescribed treatment is medically reasonable and necessary in reference to accepted standards of medical practice within the community for treatment of this patients condition.
Please fax 24/7 to (888) 633-7360.
Lgmedsupply Customer Reviews
Customer Reviews
  • Star Rating for Lgmedsupply
    Have bought many items for LG Medical since 2012 and never had an issue. Service is always great and the products are excellent quality for a great price. If you have a question and call they are knowledgeable about their products plus the LG web site has many videos and tips. I will continue to buy from LG Medical as I feel the are one of the best in their field. DMD
  • Star Rating for Lgmedsupply
    A family member ordered from LGMedSupply in the past and had great service, and that is why I felt safe ordering from them. And they didn't let me down. I got exactly what I ordered and it got to me when it was supposed to so that is why I gave them the top rating.
  • Star Rating for Lgmedsupply
    I injured my hip bowling. I am a 45 year old female and I thought I had to live with this deep aching annoying pain for the rest of my life; it had been ongoing for 3 years. Oh my goodness this Tens unit changed my life in 3 days.
  • Star Rating for Lgmedsupply
    My husband had a very painful back problem and we ordered a TENS unit from LG. We got it in a couple of days and are delighted with the service from LG and the efficiency of the TENS unit.
  • Star Rating for Lgmedsupply
    I did not understand fully how to use the Tens Unit. Lucy with customer service was SO patient and walked me through the entire process My feet felt better just after one session!
  • Star Rating for Lgmedsupply
    I purchased this unit after having a knee replacement. I decided to go with the unit that had EVERYTHING ( the price of the unit was the price of two trips to the doctor, it pays for itself).
Leading USA Supplier of TENS Units, Muscle Stimulators & Ultrasounds Units
Our brand name units come with a 5 year warranty and a 30 day full money back satisfaction guarantee. If for any reason you are not 100% satisfied, you may return your product for a full refund. Our devices come with Quick Start Guides and manuals so you can experience, safe and effective pain relief within minutes. Have questions? Email us or call us at (888) 633-7360. We ship daily Monday to Friday. All products on the website are in-stock for same day shipping when ordered before 2pm. We look forward to becoming your one stop shop for drug free pain relief. We look forward to working with you and hope to hear your success story.
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