Equipment Recommendation


 Clinic:

 Patients Name:

 Telephone:

 Condition:
   

 Date:

 Address:

 

 

  Aquaflex Weighted Vaginal Cone Set

  ELPHA II 3000 Muscle and Nerve Stimulator

  P.F.X.II-V Pelvic Floor Exerciser - Vaginal

  P.F.X.II-A Pelvic Floor Exerciser - Anal

  FemiScan Home Trainer

  FemiScan Incotrode Sensor

  GyneStim Trophic Continence Stimulator

  Femelex Vaginal Probe

  6340 MSB-A Rectal Probe

  "In Control Again" Workbook

  "Womans Waterworks" Booklet

  Purchase

  Rental

Notes:
 
 
This recommendation identifies quality equipment deemed appropriate for this individual.  The determination of such a recommendation is based upon the professional judgment 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
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)

BIOMATION - Customer Service Toll Free 1-888-667-2324