EQUIPMENT RECOMMENDATION FORM

Complete this form and Fax to 613-256-5872

Clinic:_____________________________________________________________________________________________________ Date: ________________________________

Patients Name: _____________________________________________________________________________________________________________

Address: _____________________________________________________________________________________________________________________________________

Telephone Number: ____________________________________________________

Condition: ___________________________________________________________________________________________________________________________________

Equipment Recommendation

Elpha II 3000 Muscle and Nerve Stimulator

Elpha II 1000 TENS

ActiStim A-2100 Trophic Muscle Stimulator

ActiStim A-2100 Trophic Facial Stimulator

Neuromove NM900 EMG Controlled Muscle Stimulator

GeniStim 330 HVPC Galvanic Stimulator

IF-8000 Interferential Therapy Unit

Other ______________________________________



   Purchase              Rental

Authorized by:

Client

Recommended by:

Therapist's Signature

Please print name:

Therapist

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.


- 1 copy to Therapist    - 1 copy to Insurance Company
- 1 copy to Biomation   - 1 copy to Client

Biomation  EQUIPMENT RECOMMENDATION FORM - English pdf file

Biomation  EQUIPMENT RECOMMENDATION FORM - French pdf file


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