Medtronic

Meniett® Low-Pressure Pulse Generator Prescription Form For Physicians

It is very important that you fill out this form completely and fax it on the same day as your patient's appointment to 800.678.3995.

   Physician Information
Date:  
Name:  
Phone:  
Fax:  
E-mail:                                                     @
Address:  
City:  
State:  
Zip:  
Physician Signature:  
   Patient Information
Name:  
Phone:  
Email:  
Best time of day to call:                                                a.m.        p.m.
Address:  
City:  
State:  
Zip:  

For your convenience, you may print this prescription form to bring to your doctor's appointment. This form must be completed and signed by your doctor, then faxed to 800.678.3995.

If Medtronic Xomed has not contacted you within 48 hours after your doctor faxed your prescription, please contact your doctor to make sure the prescription form was faxed properly.

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Version 2.11.0
                     Published: January 28, 2004

                    Last Updated: December 22, 2005
                    Important Safety Information! 
      All articles and graphics copyright © Medtronic Xomed, Inc. 2002 - 2003. All rights reserved. The Meniett® Low-Pressure Pulse Generator can
      only be used with a doctor's prescription. If you would like to order a Meniett device and have a doctor's prescription, click here. Meniett® is 
      a trademark of Medtronic Xomed, Inc. Innovar® is a registered mark of Johnson & Johnson Corp. Dyazide™ is a trademark of 
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