FETALSURE FETAL DOPPLER HOME USE FORM Please complete the customer portion of the form. Have your health-care provider complete the provider portion. If your health-care provider needs information on any unit, they can visit the FetalSure home page: http://www.fetalsure.com WHEN COMPLETED, FAX THIS FORM TOLL FREE: 1-866-790-5168 CUSTOMER PORTION Patient Name:______________________________ Phone:  _______________ Address:  _______________________________________________________ City:_______________________________ State:  ______ Zip:  _____________ FETAL DOPPLER INFORMATION Model: Hi Bebe BT-200 Probe: 2 MHz OB Maker:Bistos Co.,Ltd ~ 106 Daerung technotowm 3, 448, Gasan-Dong, Geumcheon-Gu, Seoul,korea Doppler Technology: Continuous Wave (CW) Unfocused. Display Rate (BPM):50 to 240 FetalSure Code: BT200 LICENSED HEALTH-CARE PROVIDER PORTION Health-Care Provider Name:  ________________________________________ Address:  _______________________________________________________ City: _______________________________ State: ______Zip: _____________ Signature: ____________________________________ Date:______________   FetalSure ~ PO BOX 397 ~ Canfield ~ OH ~ 44406 Phone 1-800-598-3487 Fax: 1-866-790-5168