PainTechnology Prescription Form User Manual
2012-05-05
User Manual: PainTechnology Prescription-Form
Open the PDF directly: View PDF 
.
Page Count: 1
| Download | |
| Open PDF In Browser | View PDF |
Patient's Name _______________________________________________________ Address ____________________________________________________________ City ________________________ State _______________________ Zip ________ Day Phone __________________________Evening Phone ____________________ E-mail ______________________________Fax _____________________________ Method of Payment: Check Enclosed (US Currency Only)_______ Master Card_______ Visa________ Card # ______________________________________Exp. Date_______________ Name on Credit Card__________________________________________________ Credit Card Billing Address _____________________________________________ City ________________________ State _______________________ Zip ________ Signature __________________________________________________________ Name of your licensed health care provider _________________________________ License # ___________________________________________________________ Dr's address _________________________________________________________ City ________________________State _______________________Zip __________ Diagnosis code _______________________________________________________ Doctor's Phone Number ________________________________________________ Doctor's Signature ____________________________________________________ Print out (CTRL P TO PRINT) and mail or fax form to Pain Management Technologies, Inc. 1340 Home Avenue, Building A Akron, OH 44310 FAX: 888-304-5454
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.4 Linearized : No Page Count : 1 Page Layout : SinglePage Page Mode : UseNone Creator : Create Date : 2012:05:05 13:31:18 Producer : Softplicity Author : Title : Subject :EXIF Metadata provided by EXIF.tools