Therapeutic Device Prescription Application

Therapeutic Device Prescription Application
Welcome! Our simple online application process is designed to make accessing therapeutic devices easy and hassle-free. Begin by submitting your application and filling out the required forms. Once completed, we will review your information to determine eligibility. If you qualify, we will send you the necessary documents to move forward. It's a simple process to help you get the care tools you deserve.

Statement of Accuracy, Responsibility and Indemnification
By submitting this application, I affirm that all information provided is true, accurate, and complete to the best of my knowledge. I understand that I am applying for a therapeutic device that requires a valid prescription based on medical necessity. This device is not for leisure or recreational use.

Important: Prescriptions cannot be backdated. Most regulations require a valid prescription before purchase or final delivery of your device. If you obtain the device beforehand, it may not qualify as a prescribed medical device, and we cannot adjust the prescription date. To ensure compliance, check with your retailer before purchasing, as we are not responsible for any issues related to timing.

By proceeding, you accept full responsibility for the accuracy of your information and agree to hold the doctor and their practice harmless from any legal or financial consequences resulting from inaccuracies or misrepresentation.
Acceptance*

I acceptI do not accept
HIPAA SUMMARY OF PRIVACY NOTICE

We follow all current HIPAA guidelines to protect your privacy and health information. For the most up-to-date details please see our attached HIPAA and Privacy Policy.

Informed Consent
I hereby request and consent to the performance of a chiropractic evaluation, telecommunication (including, but not limited to phone calls, SMS text, e-mails and voicemails) and/or any clinical services/recommendations that are deemed necessary in my case. I understand that this consultation and examination does not serve or hold itslef out to be legal or tax advice. I further understand that all telemedicine services take place in the state of Texas.

I have read the above consent and I have had an opportunity to ask questions regarding its content. By signing below, I agree to the above and intend this conset to cover my entire course of treatment for my present condition and for any future condition(s) for which I seek treatment with this office.
Signature*

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Date*

MonthDayYear
Today's Date

1. About You
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Please enter your date of birth
Gender*

MaleFemale
Please provide a picture of your legal I.D. for verification*

Cancelof
How were you referred to our service?*
Would you like us to send your prescription directly to your hot tub retailer/salesperson listed above?*

YESNO
Please provide us with the email address so we can send over the forms:*
example@example.com
I authorize Renew & Restore Wellness to share a copy of my completed forms and prescription with the individual(s) designated above. I understand that this may include sensitive health information and I release Renew & Restore Wellness from any liability related to this disclosure.
Signature*

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"I confirm that the information being submitted is accurate and truthful to the best of my knowledge."
Signature*

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Date

MonthDayYear
Date

Payment*

Therapeutic Device Prescription Application (CPT 99422)Prescription from Renew & Restore Wellness

$97.00

Total

$0.00

Statement of Accuracy, Responsibility and Indemnification