Please print out and mail.

WRITTEN ORDER FOR EXTERNAL VACUUM ERECTION DEVICE

Patient Name   __________________________________________

Address            __________________________________________

Patient Phone  __________________________________________

Patient Medicare No.  _____________________________________

I prescribe the use of an external vacuum device for the management of organic impotence (607.84 ICD-9-CM) for the patient named above. (Please describe patient’s contributing factors of erectile dysfunction; i.e. diabetes, heart disease, hypertension, prostate cancer…)

______________________________________________________

______________________________________________________

Physician signature: ______________________________________

UPIN:_____________________ Date:________________________                                          

PHYSICIAN INFORMATION:  

Name: __________________________________________________

Address: ________________________________________________

City, St, Zip:______________________________________________

Phone:_________________ Fax:_________________ UPIN: _______

Please print this order and take it to your doctor for completion.
Upon receipt of this signed form, we will send the Elite Custom to you promptly.

Return this signed original to:

American Diabetic Supply, Inc.  
400 S. Atlantic Ave. Suite 108     Ormond Beach, FL  32176
1-800-453-9033