Cartridge Form

Instructions

Complete all the requested information in the prescription form below for one or more cartridges. A single form can be used if all prescriptions are identical. Simply indicate the number of copies by filling in the space labeled "number of times this prescription is to be programed."

PLEASE INCLUDE A SIGNED PHYSICIAN'S PRESCRIPTION SHEET WITH THIS FORM

Send completed forms to:  Therapeutic Alliances Inc.
                          333 N. Broad Street
                          Fairborn, Ohio  45324
                          (937) 879-0734
              Or fax to:  (937) 879-5211

Cancel unused sessions from previous prescription(s)? _____

Today's date: ________   Patient name: _____________________

Physician name: _________________________

Number of sessions: ___ (1 - 36)   Sessions per week: ___ (1 - 7)

Maximum stimulus time per session: ____ (3 - 30) minutes

Maximum stimulus time per run: ____ (3 - 30) minutes

Maximum resistance allowed during session: ____ (0 - 7) 1/8 Kiloponds

Rest after runs: ____ (3 - 30) minutes

Max Stim Levels, 0 - 140 milliamps (default is 140 milliamps):

RQUAD ____ LQUAD ____   RGLUT ____ LGLUT ____   RHAM ____ LHAM ____

___________________________________________________________________

 Waveform Parameters (applies only to ERGYS 2se models):
 
 Waveshape _________________    Duration ____ microsec   ____ PPS
 
 Allow ERGYS rider to change (Y/N): ____

___________________________________________________________________

  Number of times this prescription to be programed: ____ (1 - 12)
  (NOTE: Each cartridge can hold up to 4 prescriptions)

Number of cartridges (number of prescriptions divided by 4): ___