PHYSICIAN ORDER FORM - pARK aVENUE mEDICINE & sURGERY - PNS (Peripheral Nerve Stimulator) PATIENT EDUCATIONAL MATERIAL REQUEST

Patient Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth: (ex: Month, Day, Year: January, 01, 1990)

MM

DD

YYYY

Please Contact Patient for the Following:

Enroll in Patient Ambassador Program (to connect with another patient who has device)

Answer Technical and Engineering Questions about Device.

Programming/Re-Programming Existing PNS

FDA Diagnosis:

LEFT

RIGHT

BILATERAL

Greater Occipital Neuralgia

Shoulder

Elbow

Wrist

Hand

Hip

Knee

Ankle

Foot