Equipment Recommendation Form (pdf) - EnglishClinic: _____________________________________ Date: ______________________
Patients Name: _____________________________ Address: ____________________
Telephone: _________________________________
Condition: __________________________________
Equipment Recommendation:
____________________________________________________
Elpha 2000 Muscle and Nerve Stimulator
Elpha II 3000 Muscle and Nerve Stimulator
Elpha II 1000 TENS
Neuro-4 Trophic Stimulator
Biosense EMG Muscle Trainer
Neuromove NM900 EMG Controlled Muscle Stimulator
IF-8000 Interferential Therapy Unit
__________________________
Purchase
Rental
Notes: ___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
This recommendation
identifies quality equipment deemed appropriate for this individual.
The determination of such a
recommendation is based upon the professional
judgement
of the therapist(s) involved in consultation with the client.
The
client agrees to accept the equipment described above upon delivery as
authorized by his/her signature.
Authorized by: ____________________________ Recommended by: ____________________________________
__________________________________Client _______________________________________Therapists Signature
___________________________
Please print name
1 copy to Therapist
1 copy to Biomation
1 copy to Insurance Company
1 copy to Client
| Supplier:
Biomation 335 Perth Street P.O. Box 156 Almonte, Ontario Canada K0A 1A0 |
Tel:
(613) 256-2821
Toll Free:
1-888-667-2324
Fax:
(613) 256-5872
E-Mail: sales@biomation.com
|
Equipment Recommendation Form (pdf) - English
Equipment Recommendation Form
(pdf) - French
