Common Contracts
2 similar null contracts
Patient AgreementMay 2nd, 2012
Dr. REP: Date of Surgery: Procedure: UPIN# Primary Ins. Co: Phone: Address: City: State: Zip: ID/Policy#: Group#: Insured: Relationship to Insured: q Self q Spouse q Child Patient: DOB: SS#: Address: City: State: Zip: Secondary Ins. Co: Phone: Address: City: State: Zip: ID/Policy#: Group#: Insured:Relationship to Insured: q Self q Spouse q ChildClaim#(W/C): DOI: Adjuster: Home Phone: Cell Phone: WC PATIENTS ONLY Employer Name: Address: City: State: Zip: Office Phone: Delivery Date: Rented From: to Stop charge date 7 day minimum rental. Overnight rental is considered as a full day.$ per day. CPM Model: Serial#: Thermotek Model: Serial#: Sale Items (Subject to applicable sales tax):q Iceman qContrast q TSLO Back Brace qCompression Therapy (Nano) q CPM Shoulder qShldr/Knee/Back/Ankle Cold Pad q LSO Back Brace qCPM Soft Goods qCPM Knee qBack Wrap q Cervical/Vista Collar q OTS Knee Braces qCPM OtherqShldr/Knee/Back/Ankle Sterile q TENS/E-STIM qCustom Knee Brace q qPain Control Device q
Patient AgreementMay 2nd, 2012
Dr. REP: Date of Surgery: Procedure: UPIN# Primary Ins. Co: Phone: Address: City: State: Zip: ID/Policy#: Group#: Insured: Relationship to Insured: q Self q Spouse q Child Patient: DOB: SS#: Address: City: State: Zip: Secondary Ins. Co: Phone: Address: City: State: Zip: ID/Policy#: Group#: Insured:Relationship to Insured: q Self q Spouse q ChildClaim#(W/C): DOI: Adjuster: Home Phone: Cell Phone: WC PATIENTS ONLY Employer Name: Address: City: State: Zip: Office Phone: Delivery Date: Rented From: to Stop charge date 7 day minimum rental. Overnight rental is considered as a full day.$ per day. CPM Model: Serial#: Thermotek Model: Serial#: Sale Items (Subject to applicable sales tax):q Iceman qContrast q TSLO Back Brace qCompression Therapy (Nano) q CPM Shoulder qShldr/Knee/Back/Ankle Cold Pad q LSO Back Brace qCPM Soft Goods qCPM Knee qBack Wrap q Cervical/Vista Collar q OTS Knee Braces qCPM OtherqShldr/Knee/Back/Ankle Sterile q TENS/E-STIM qCustom Knee Brace q qPain Control Device q
