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