PRESCRIPTION ORDER FORM FOR TENS/EMS/IF/GALVANIC UNITS
Please print out this form, complete the top portion and middle portion (optional), have your Health Care Provider (Chiropractor, Podiatrist, Physical Therapist, Doctor of Osteopathy, Medical Doctor, Dentist, Nurse Practitioner, PH.D., or Doctor of Acupuncture) complete the bottom portion and fax it to: TOLL FREE FAX-24 Hours/Day, 7 Days/Week-(877) 512-3015 TOLL FREE PHONE -- (877) 841-2455 Patient's Name Phone Address City State Zip Unit Name(s) Qty Card# Exp. Date Name on Credit Card Signature Packs of extra Electrodes, comes with a pack of 4, $7.99 per extra pack Name of your licensed health care provider Address City State Zip Signature |