FETALSURE
FETAL DOPPLER RENTAL

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: Nicolet CareDop

Probe: 3 MHz OB

Maker: Nicolet Vascular 5225 Verona Rd. Bldg. 2 Madison WI 1-800-525-2519

Doppler Technology: Continuous Wave (CW) Unfocused.

Display Rate (BPM):N/A

FetalSure Code: PT-CT

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