SUBMIT YOUR DASH!

Patient Name:

DOB:

Phone:

Email:

Shipping Delivery Address:

Attorney/Insurance Information:

Diagnosis Codes:

Infrared Laser Pain Management DMETLumbar Belt/BraceLumbar Support PillowInversion TableCervical CollarHot / Cold PackWalker / Cane / Crutches (Please specify in notes section)Tens Unit w/ Additional Electrodes (One month’s supply)Lumber Ambulatory Traction DeviceExtremity Brace/Sling (Please list the Extremity and right/left in the notes)Cervical Pillow / WedgeCervical Traction DeviceCryotherapy Machine / Ice Cubes

Notes:

Your Name:

Please Check This Box as Your Electronic Signature

Please leave this field empty.