PainTechnology Prescription Form User Manual
2012-05-05
User Manual: PainTechnology Prescription-Form
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Page Count: 1
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
