Precision Field Patient Pay - Final

Thank you for choosing Precision Medical

Please enter your information below using our secure payment portal
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Date of Surgery

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sales Representative (Enter Name)*
Shipped to PatientIn Person
Enter Sales Order Number

Choose Product*

Circul8 Pro - Adam Veri Product Image

Circul8 Pro - Adam Veri

$150.00

Circul8 Pro - PMP Product Image

Circul8 Pro - PMP

$129.00

Circul8 Pro - Sara Schwartzman Product Image

Circul8 Pro - Sara Schwartzman

$120.00

Cryo ROM Knee Product Image

Cryo ROM Knee

Cold Therapy Knee brace

$95.00

Cryo Hip Brace Product Image

Cryo Hip Brace

Cold Therapy Hip Brace

$200.00

Cryo Ankle Brace Product Image

Cryo Ankle Brace

Cold Therapy Ankle Brace

$50.00

Cryo Shoulder Brace Product Image

Cryo Shoulder Brace

Cold Therapy Shoulder Brace

$75.00

NMES Stimulator Device Product Image

NMES Stimulator Device

Electrical Stimulator

$90.00

Breg Polar Wave Product Image

Breg Polar Wave

Cold Therapy Machine

$450.00

Breg Polar Cube Product Image

Breg Polar Cube

Cold Therapy Unit

$250.00

Vascutherm Product Image

Vascutherm

Daily Rental

$50.00 Quantity

Circul8 Extender Product Image

Circul8 Extender

DVT Device Extender

$15.00 Quantity

Cryo Back Brace Product Image

Cryo Back Brace

GForce

$150.00 Quantity

Ossur Cold Rush Product Image

Ossur Cold Rush

Includes Wrap

$225.00 Quantity

Ossur Cold Rush Compact Product Image

Ossur Cold Rush Compact

Includes Wrap

$125.00 Quantity

Aspen Multipost Collar Product Image

Aspen Multipost Collar

Cervical Collar

$160.00 Quantity

Trend Pro Product Image

Trend Pro

Unloader Brace

$229.00 Quantity

Shoulder Sling Product Image

Shoulder Sling

Ossur Shoulder Sling Form Fit

$125.00 Quantity

Standard Crutches Product Image

Standard Crutches

Adult

$49.00 Quantity

Ossur Cold Rush - Sara Schwartzman Product Image

Ossur Cold Rush - Sara Schwartzman

Includes Wrap

$150.00 Quantity

Total

$0.00

Credit Card

Prescription and/or Patient Agreement Upload

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