All Forms·Corona · InlandDME@gmail.com

TENS Order

1426 W. 6th St Suite 108 Corona, CA 92882 · (951) 278-1222

Patient Name

Date of Birth

Address

Phone #

Insurance

IEHPCash Pay

We do not bill Medicare for this item.

TENS Device, four or more leads

TENS Stimulation Pad Supplies

Diagnosis / ICD-10 Code(s)

Prescriber Name

NPI #

Office Address

Phone #

Prescriber Signature

Sign here

Date

Attachments (optional)

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