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