Physician’s Order Download this form as a PDF Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Phone*DOB*Sex*FemaleMaleDiagnosisICD-10 CODE*Length of NeedLast Face-to-Face DateMedical Records IncludedYesNoUpload Medical RecordsWeightHeightReason for Need/Medical NecessitySpecific Supplied Ordered*I, the undersigned, certify that the above prescribed equipment/supplies is medically necessary as part of my treatment for this patient. In my opinion, the equipment prescribed is reasonable and necessary for accepted standards of medical practice and treatment of this patient's condition and has not been prescribed as "convenience equipment".Physician Name*Phone*Fax*Physician Address* Street Address City State / Province / Region ZIP / Postal Code NPI***Frequency of Use***Date* MM DD YYYY Physician Signature*