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CPR Medical
Supply Questionnaire
Fields in red are required for completion.

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.

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?)   
   
Need more electrodes.  (If checked, how many packages do you need monthly?) 
   
Unit no longer needed.  Please indicate how you will return the unit... 
   
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