TENS PRESCRIPTION FORM

Please print out this form, complete the top portion, have your Health Care
Provider ( Chiropractor, Dentist, Podiatrist, Nurse
Practitioner, Physicians Assistant, Ph.D., Physical Therapist, Doctor of
Acupuncture or Doctor of Osteopathy, Medical Doctor) sign it and mail or fax it in today.

THIS FORM REQUIRED FOR USA ORDERS ONLY!
(Please Print)

Patient's Name_______________________________________________________
Address ___________________________________________________________
City ______________________ State _____________________ Zip ___________
Day Phone________________________Evening Phone _____________________
E-mail_____________________________Fax _____________________________
Signature ________________________________________________________
Units prescribed: ________________________________________________

Name of your licensed health care practitioner _______________________________
License # __________________________________________________________
Dr's address ________________________________________________________
City_______________________State____________________Zip ____________
Doctor's Signature __________________________________________________

Print out and mail/fax form to:
INNOVATIVE MEDICAL MODALITIES
2741 W. SOUTHERN AVE. STE. 13
TEMPE ARIZONA 85282
FAX: (1-602-438-8722) PHONE(1-602-438-8722)