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
on the top right corner of your packing list and begins with "A",
Please check the appropriate
Need electrodes. (If checked, how many packages do you need)
supplies needed (please explain in the box below).
Your e-mail address
Please call us Toll Free if
you have any questions