Prescription Form

Prescription Request Form

Date (mm/dd/yyyy)

Full Name *

First

Last

Date of Birth (mm/dd/yyyy)

Email *

Home Street Address (Include State and Zip Code)

Cell Phone (+ area code): *

Home Phone (+ area code):

Sex

CONTRAINDICATIONS FOR ARP:

NOTE: FDA requires that you answer "Yes" or "No" to EACH of the following six questions. If you have a contraindication, please notate it, scroll down to the bottom of this form, and click submit. If you do not have a contraindication, please notate and continue filling out the form; hit submit once the form is completed. Unfortunately, if you have a contraindication listed below, FDA will not allow ARPwave to ship or utilize any ARPwave devices with you.

1. Pregnant *

2. Blood Clots *

3. History of Blood Clots *

4. Pacemaker *

5. ICD *

6. Any implanted electrical device other than Pacemaker or ICD *

List the areas of where you are experiencing pain in the order you want to work on.

Where is your pain located:

Rate the intensity of your pain:

When did your complaint/symptoms begin:

What was the cause of the symptoms:

What does your pain feel like:

How have the symptoms progressed:

What movement or activity bothers you most:

Have you had surgery:

Have you been told you need surgery:

What have you done to relieve symptoms?

List any medication you are taking:

Have you had Physical Therapy as a treatment:

Have you had Chiropractic as a treatment:

Your Primary Physician name:

Your Primary Physician Phone:

Truthful Representation:

Upon entering my full name below, I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell the doctor when possible so that it can be added to my record.