Vivally Intake Form

PATIENT INFORMATION
Name*

FIRST NAMELAST NAME
GENDER*
DOB (MM/DD/YYYY)*
Diagnosis Code (ICD-10)*

N32.81 OveractiveR32- Unspecified Urinary IncontinenceR39.15 Urgency of UrinationTypeR39.41 Urge IncontinenceOther
MEDICAL NECESSITY - TRIED / FAILED TREATMENTS FOR URINARY INCONTINENCE*

Behavioral ModificationPharmacologies Include previous tried & failed treatments and side effects in the most recent medical record notes.Other
MEDICAL PRESCRIPTION

Vivally System E0737
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.
REQUIRED FIELDS
PRESCRIBERS SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Name*

FIRST NAMELAST NAME
NPI*
RECOMMENDED FIELDS - (EMAIL MAY BE REQUIRED FOR ACCESS TO PATIENT VIVALLY THERAPY DATA)
PRESCRIBERS DESIGNATED CONTACT PERSON
PRESCRIBERS DESIGNATED CONTACT PHONE NUMBER
PRESCRIBERS DESIGNATED CONTACT EMAIL
example@example.com

NAME -FIRST LAST*
GENDER*
DOB (MM/DD/YYYY)*
Address*

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
MOBILE PHONE *
EMAIL*
example@example.com
PREFERRED WRITTEN LANGUAGE*
PREFERRED SPOKEN LANGUAGE*
EMERGENCY CONTACT*
EMERGENCY PHONE*
INSURANCE
PRIMARY PAYER NAME*
ID #*
GROUP #*
PHONE*
POLICY HOLDER DOB (MM/DD/YYYY)*
PRIMARY POLICY HOLDER NAME*

First NameLast Name
RELATIONSHIP TO PATIENT*
SECONDARY PAYER
ID #
GROUP #
RELATIONSHIP TO PATIENT
SECONDARY POLICY HOLDER NAME
POLICY HOLDER DOB
RELATIONSHIP TO PATIENT
PATIENT SIGNATURE*

Clear
Date*
PERSONAL REPRESENTATIVE
Personal representative: If the individual signing this form is not the patient, please print name and specify relationship to the patient; if Power of Attorney, please provide documentation.
PERSONAL REPRESENTATIVE,
Date
PDF
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Secure Prescriber Fillable Form Avation.com Prescriber Kit

Call Avation Customer Care at 888.972.5694 for assistance

COPYRIGHT © 2023 2025, AVATION MEDICAL, INC. ALL RIGHTS RESERVED. AVATION MEDICAL AND VIVALLY ARE TRADEMARKS OF AVATION MEDICAL. MKT 002-00143

FULL NAME *
Medical Practice Name*
Patient or Legal Representative Signature Authorizing Release*

Clear
Printed Name*
Date*

MonthDayYear
Date
Patient or Legal Representative Signature for Appointment of Representative*

Clear
Legal Representatives Relationship to Patient
Printed Name
Date

MonthDayYear
Date

NAME - FIRST & LAST*
DOB (MM/DD/YYYY)*
Address*

SHIPPING ADDRESS

Street Address Line 2

CITYSTATE

ZIP
MOBILE PHONE*
EMAIL*
example@example.com
ii. Measure:Measurement 1: Ankle Circumference just above ankle bone on bare ankle. Record Measurement 1 in centimeters.*
Measurement 2: Middle of Foot Circumference at the arch on bare foot. Record Measurement 2 in centimeters.*
DETERMINE VIVALLY SIZE WITH SIZING GUIDE & SELECT SIZE*

Vivally Small. Ankle AND Foot measure between 19.0 cm - 23.9 cmVivally Medium. Ankle OR Foot measure between 24.0 cm - 28.5 cmVivally Extender. Ankle OR Foot measure greater than 28.5 cm