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:____________________________________________

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

Biomation EQUIPMENT RECOMMENDATION FORM - English pdf file
Biomation EQUIPMENT RECOMMENDATION FORM - French pdf file


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