Patient Information Request Form
Which units are you currently interested in?
Where is your source of pain?
Have you used electrotherapy before? Yes
No
If yes, where? At Home
Physicians Office
On a scale of 1 to 10, 10 being the highest, what is your level of pain?
Are you currently seeing a physician for your symptoms? Yes No
If yes, what is his/her name and phone number?
Name
Phone
Would you like us to contact him/her regarding a unit for you? Yes No
Would you like us to locate a participating physician in your area? Yes No
Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
Fax
E-mail
Would you like us to verify your insurance for coverage of a unit? Yes No
If yes, what is the name of your insurance company?
What is the type of insurance? Health Auto Comp
What is your policy/claim #:
What is your Date of Birth:
Please enter the customer service phone number listed on the back of your insurance card:


 
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