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PATIENT INFO

Patient Name: DOB: Phone: Email: Shipping Delivery Address: Attorney/Insurance Information:

CODES

Diagnosis Codes:

SELECT ITEMS

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:

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