• PLEASE SELECT ONE OF THE FOLLOWING

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • COPYRIGHT© 2023 - 2026. AVATION MEDICAL. INC. ALL RIGHTS RESERVED. AVATION MEDICAL AND VIV ALLY ARE TRADEMARKS OF AVATION MEDICAL. - MKT 002-00143

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  • Date*
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  • Date
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  • PATIENT INFORMATION

  • Shoe Size
  • Wide Fit
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  • 2 MEDICAL DIAGNOSIS Diagnosis Code (ICD-10):
  • 5 MEDICAL NECESSI TRIED/FAILED TREATMENTS FOR URINARY INCONTINENCE

  • PRESCRIBER INFORMATION

    This form serves as a Standard Written Order and Prescription for the Vivally System for this patient. As this patient's Prescriber, I attest that the clinical information in this document accurately reflects the patient's health status and condition. I further certify that the Vivally System is reasonable and medically necessary for the treatment of this patient's condition. I understand that my email address and a secure login to the Vivally System may be required for me to access Vivally System data for this patient.

  • Date
     - -

  • RECOMMENDED FIELDS -(EMAIL MAY BE REQUIRED FOR ACCESS TO PATIENT VIVALLY THERAPY DATA)

  • Format: (000) 000-0000.
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