Meniett Prescription Form_Rev5.1pmd.p65

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					MENIETT LOW-PRESSURE PULSE GENERATOR PRESCRIPTION FORM
                 ®




Physician Information                                                     Date: __________________________________________________

Name: _______________________________________________________________________________________________________________________

Phone: ______________________________________________ Alternate phone: _________________________________________________

Fax: ________________________________________________       E-mail: _____________________________________________________________

Address: ____________________________________________________________________________________________________________________

City, state, zip: _____________________________________________________________________________________________________________

Physician signature: _______________________________________________________________________________________________________


Patient Information
Name: _______________________________________________________________________________________________________________________

Daytime phone: ( ________ ) _______________________________ Evening phone: ( ________ ) _________________________________

Best time of day to call: _______ AM            ________ PM         Email: _______________________________________________________

Address: ____________________________________________________________________________________________________________________

City, state, zip: _____________________________________________________________________________________________________________

Name of insurance carrier: _________________________________________________________________________________________________

Phone number on insurance card: _________________________________________________________________________________________
Medtronic ENT uses insurance information only to track reimbursement trends.

Patient signature: ___________________________________________________________________ Date: _________________________________________
___________ Yes, I am willing to be contacted regarding reimbursement of this device.


For your convenience, you may print this prescription form to bring to your doctor’s appointment. This form must be
completed and signed by your doctor, then faxed to 866-463-8726.

If Medtronic ENT has not contacted you wtihin 48 hours after your doctor has faxed your prescription, please
contact your doctor to make sure the prescription form was faxed successfully.


                                                                                            ®
                                                                                                Registered mark of Medtronic Xomed, Inc.   890111   05.07   2007-326   Rev5.1

				
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