In order to better service our patients, please fill out this CPR Medical Questionnaire.

IMPORTANT: Your insurance company requests that this questionnaire be completed and returned, with each supply shipment you receive.  Failure to do so could result in the suspension of supply shipments.

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Name      

Date (00/00/0000)   

Phone (123-456-7890)

Please check the appropriate box (boxes):
    Continue monthly supply shipments.
    Need less electrodes.  (If checked, how many packages do you need monthly?)    No Change 3 pkg monthly 2 pkg monthly 1 pkg monthly I will call when I need more. Other... Please specify below.
    Need more electrodes.  (If checked, how many packages do you need monthly?)  No Change 4 pkg monthly 3 pkg monthly 2 pkg monthly 1 pkg monthly Other... Please specify below.
    Unit no longer needed.  Please indicate how you will return the unit...  Still Using I have a return label and will send the unit back. Please send me a return label, so I can return the unit. Please call me, I need to make other arrangements.
    Other ... Please add your comments or questions in the box below.
                       

Your e-mail address

Please call us Toll Free if you have any questions

1-800-235-5675