Equipment Recommendation

Clinic:  _____________________________________ Date:  ______________________

Patients Name:  _____________________________ Address: ____________________

Telephone:  _________________________________

Condition:  __________________________________

Equipment Recommendation:  ____________________________________________________

     Elpha 2000 Muscle and Nerve Stimulator

      Elpha II 3000 Muscle and Nerve Stimulator

      Elpha II 1000 TENS

      Neuro-4 Trophic Stimulator           

      Biosense EMG Muscle Trainer   

      Neuromove NM900 EMG Controlled Muscle Stimulator

      IF-8000 Interferential Therapy Unit  

      __________________________

      Purchase

      Rental

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.

Authorized by:  ____________________________     Recommended by:  ____________________________________

__________________________________Client    _______________________________________Therapists Signature

                                                                                                                         ___________________________
                                                                                                                                               Please print name
1 copy to Therapist
1 copy to Biomation
1 copy to Insurance Company
1 copy to Client

  Equipment Recommendation Form (pdf) - English

  Equipment Recommendation Form (pdf) - French

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