Vivally

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PATIENT INFORMATION
Name

FIRST NAMELAST NAME
GENDER
DOB MMDDYYYY
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.
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 MMDDYYYY
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 POLICY HOLDER NAME
ID #
GROUP #
PHONE
POLICY HOLDER DOB
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
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Avation Medical PO Box 736474 Chicago, IL 60673-6474

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.
Type a question

Vivally SmallAnkle AND Foot measure between 19.0 cm - 23.9 cmVivally MediumAnkle OR Foot measure between 24.0 cm - 28.5 cmVivally ExtenderAnkle OR Foot measure greater than 28.5 cm

File Upload

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REQUIRED FIELDS

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

INSURANCE

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