Prescription Fax Form

Please print and fax the below form to 781-769-9268

Prescription
Patient _______________________________Date __________
Diagnosis ____________________________________________
Electrical Modalities
TENS for management of pain
Muscle Stimulation
Other: ____________________________________________
Traction Devices
COMFORT NECK TRAC Supine
SAUNDERS NECK TRAC Supine
Other: ____________________________________________
Supports
ANKLE support (type)
WRIST support (type
LUMBAR support (type)
KNEE support (type)
Ligament knee bracing
Patello-Femoral bracing
Post-op bracing
Other: ____________________________________________
Frequency and Duration: