Dr.'s Prescription
PLEASE FAX TO: 707-598-7276


FOR PATIENTS NAME: ______________________

FOR:

___TIMER TENS	___MICROCURRENT
___ SD TENS	___INTERFERNTIAL
___EMS	___GALVANIC STIM

SIGNED:__________________ MD-DATE:___/___/___
(FOR ASSISTANCE: 1-800-TENS-UNIT)