Please print out this form, complete the top portion, have your Health Care Provider (Medical Doctor, Chiropractor, Dentist, Podiatrist, Nurse Practitioner, Physicians Assistant, Ph.D., Physical Therapist, Doctor of Acupuncture or Doctor of Osteopathy) sign it and mail or fax it in today. Please note: you can use the doctor's form if it is more convenient. FAX (561) 251-0332 | PHONE (561) 251-0332
PRESCRIPTION FORM
THIS FORM REQUIRED FOR USA ORDERS ON ALL ELECTRO-MEDICAL DEVICES!
(Not required for international orders.)
(It is not necessary to use this form only)
Thank you for your order!!!
Patient's Name_______________________________________________________
Address ____________________________________________________________
City ________________________ State _______________________ Zip ________
Day Phone__________________________Evening Phone ____________________
E-mail______________________________Fax _____________________________
Method of Payment:
Check Enclosed (US Currency Only)_______ Master Card_______ Visa________
Card # ______________________________________Exp. Date_______________
Name on Credit Card__________________________________________________
Credit Card Billing Address _____________________________________________
City ________________________ State _______________________ Zip ________
Signature __________________________________________________________
Name of your licensed health care provider _________________________________
License # ___________________________________________________________
Dr's address _________________________________________________________
City________________________State_______________________Zip __________
Diagnosis code _______________________________________________________
Doctor's Phone Number ________________________________________________
Doctor's Signature ____________________________________________________
--------------------------------------------------------------------------------
Print out (CTRL P TO PRINT) and mail or fax form to
Microcurrent Shoes
2200 N.E.2nd ave
Boca Raton, Florida 34431
Phone: 561-251-0332
Email: mailto:forms@microcurrentshoes.com
FAX: 561-251-0332
