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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