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      

Customer Number    (located on the top right corner of your packing list and begins with "A", e.g. A12345)

Date (00/00/0000)   

Phone (123-456-7890)

Please check the appropriate box (boxes):
    
    Need electrodes.  (If checked, how many packages do you need)    1 2 3 4
    
    Other supplies needed (please explain in the box below).
                       

Your e-mail address

Please call us Toll Free if you have any questions

1-800-235-5675