CustomCare Prescription

To prescribe a unit to a patient, please submit this form.
Prescribing Practitioner Name*

First NameLast Name
Practitioner Email*
example@example.com
Practitioner Phone Number*

Area CodePhone Number
Patient Name (for reference on your account)*

First NameLast Name
Patient Phone Number*

Area CodePhone Number
Who will be paying for the unit?*

PractitionerPatient
Patient Phone Number*

Area CodePhone Number
CustomCare units can be ordered pre-programmed for a $50 programming fee. Please fill out the CustomCare programming form here.
Please Verify Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Accessories Patient Needs

Programming Cable (required for remote programming) - $85.00Bum Bag - $20.00Magnetic Converter - $2095.00Sticky Pads - $7.00Extra Crocodile Clips - $25.00Extra Lead Wires - $100.00Resonance Wraps - $65.00Graphite Gloves - $140.00
Additional instructions:
Should be Empty: