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?) 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