Physician/Therapist Name (required)

Phone Number (required)

Device to Verify (required)
TENSMstimINFGarment ElectrodeCervical Traction UnitUltrasound Unit

Primary Diagnosis Codes

Patient Name (required)

Patient DOB (required)

Patient SS# (required)

Insurance Carrier (required)

Insurance Phone Number (required)

ID/Policy Number (required)

If WC or Auto Accident Date of Injury