Name of referring doctor or professional: *
Clinic Name:
Clinic Address:
City:
Province:
Postal Code:
Mailing Address(if different):
Phone No. *
Fax No.
Email:
Profession: Medical Doctor Physiotherapist Chiropractor Naturopath Orthopedic Surgeon Other
Please provide the following patient information.
Patient Name: *
Patient Address:
Alt. Phone No.
Comments:
I have prescreened the above patient for medical conditions that could be contrary to inversion, including the medical contraindications listed here: Medical Warnings.
This patient is a safe candidate for inversion and may proceed with purchasing an Invertrac unit for their own personal use.
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