Prescribing Physician (Your) Full Name
*
Prefix
First Name
Last Name
Suffix
Your NPI
*
Your email (or medical assistant). A copy of this signed prescription will emailed to you for your records.
*
example@example.com
Clinic Phone
Patient Name
*
Prefix
First Name
Last Name
Suffix
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Primary Diagnosis Code
*
Note: Specific Diagnosis Code, to include affected limb
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Product Prescribed
*
Laterality
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LEFT
RIGHT
Product Code
*
Product Description
*
Provider's Signature
*
By my signature, I am prescribing the item listed. In my judgment, the prescribed item is medically indicated in necessary and consistent with current accepted standards of medical practice and treatment of the patient's physical condition.
Prescription
*
By my signature, I am prescribing the item listed. In my judgment, the prescribed item is medically indicated in necessary and consistent with current accepted standards of medical practice and treatment of the patient's physical condition.
Date
*
/
Month
/
Day
Year
Date
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OPTIONAL: Do you have a local representative?
If you would like us to work with your preferred rep, please include this information.
Rep Name
First Name
Last Name
Rep Email
example@example.com
Rep Phone Number
Please enter a valid phone number.
Should be Empty: