Order
Form Fill
out
form
completely
and
mail
to:
Diabetes
Home
Care
P.O.
Box
265
Crescent
City,
Florida
32112
The
Complete
Erectile
Dysfunction
system
$420.00
Doctor's
Prescription
required
for
all
orders.
Medicare
Assignment
accepted.
Please
call
for
Private
Insurance
coverage
information
Name:
Address:
City,
State
&
Zip:
Phone:
MC/Visa/AmEx
Card
#
Expiration
Date:
Signature:
PHYSICIAN
INFORMATION:
(To
be
filled
out
by
attending
physician)
Name:
Address:
City,
State,
&
Zip:
Phone
Number:
Specialty:
Written
Order
for
External
Vacuum
Erection
Device
Patient:
Patient
Medicare
#
I
prescribe
the
use
of
an
external
vacuum
erection
device
for
the
management
of
organic
impotence
(ICD-9-CM
Code
607.84)
for
the
named
patient
above.
Please
describe
patient's
contributing
factors
of
erectile
dysfunction: