FertiCare Personal Order Form
PATIENT INFORMATION: (Please Print)
| Patient Name: |
| Address: |
| City / State / Zip Code: |
Phone Number: Date of Birth:
How did you hear about FertiCare Personal?
PHYSICIAN PRESCRIBING INFORMATION: (Please Print)
Patient's Primary Diagnosis:
Address:
| City / State / Zip Code: |
| Phone Number: |
| UPIN Number: |
| Medical Specialty: |
"I prescribe and request a FertiCare Personal Vibrator for my patient named above because FertiCare Personal Vibrator is medically necessary"
Physician's Signature: Date: