EQUIPMENT RECOMMENDATION FORM

Biomation

 Printable Form English

Complete this form and Fax to 613-256-5872

Biomation

 Printable Form French






Clinic:_____________________________________________________________________________________________________ Date: ______________________________

Patients Name: _____________________________________________________________________________________________________________

Address: _____________________________________________________________________________________________________________________________________

Telephone Number: ____________________________________________________

Condition: ___________________________________________________________________________________________________________________________________

Equipment Recommendation

Checkbox  Elpha II 3000 Muscle and Nerve Stimulator
Checkbox  Elpha II 1000 TENS
Checkbox  ActiStim A-2100 Trophic Muscle Stimulator
Checkbox  ActiStim A-2100 Trophic Facial Stimulator
Checkbox  Neuromove NM900 EMG Controlled Muscle Stimulator
Checkbox  GeniStim 330 HVPC Galvanic Stimulator
checkbox  IF-8000 Interferential Therapy Unit
checkbox

 Other ______________________________________

 checkbox Purchase        checkbox Rental

Authorized by
Name of Client:  _______________________________________________________________________________________________________________________________________

Therapist Signature:  __________________________________________________________________________________________________________________________________

Therapist 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 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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