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Please print out this form, complete the top portion, have your Health Care Provider (Medical Doctor, Chiropractor, Dentist, Podiatrist, Nurse Practitioner, Physicians Assistant, Ph.D., Physical Therapist, Doctor of Acupuncture or Doctor of Osteopathy) sign it and mail or fax it in today. Please note: you can use the doctor’s form if it is more convenient. FAX (888) 304-5454 | PHONE (888) 267-5422

PRESCRIPTION FORM

THIS FORM REQUIRED FOR USA ORDERS ON ALL ELECTRO-MEDICAL DEVICES!
(Not required for international orders.)

(It is not necessary to use this form only)

Thank you for your order!!!

Patient's Name_______________________________________________________

Address ____________________________________________________________

City ________________________ State _______________________ Zip ________

Day Phone__________________________Evening Phone ____________________

E-mail______________________________Fax _____________________________

Method of Payment:

Check Enclosed (US Currency Only)_______ Master Card_______ Visa________

Card # ______________________________________Exp. Date_______________

Name on Credit Card__________________________________________________

Credit Card Billing Address _____________________________________________

City ________________________ State _______________________ Zip ________

Signature __________________________________________________________

Name of your licensed health care provider _________________________________

License # ___________________________________________________________

Dr's address _________________________________________________________

City________________________State_______________________Zip __________

Diagnosis code _______________________________________________________

Doctor's Phone Number ________________________________________________

Doctor's Signature ____________________________________________________