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Prescription/Rx Form for In-Home Vaso-Pneumatic Compression Device


Pneumatic Compression Devices


Please check the conditions that apply to the patient:

OR

Patient Instructions:

        
        

Contraindications: DVT, PE, Uncontrolled CHF, Infected Wound, and Gangrene

Measure the larger leg. Measure in inches.

Please fax signed Prescription/Rx, Progress Notes, and Face Sheet to:
VasoCARE @ 1-866-455-5150

© Copyright 2019-Present VasoCARE, LLC

For best results, check “Shrink to Fit Page” in your print dialog if available. If you have issues printing this form, please download and use the PDF version.