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Unit Prescribed

Please choose 1 ONLY

Please refer to the Innovo sizing guide: https://www.myinnovo.com/pages/sizing-guide

Please choose 1 ONLY





Patient Demographics Information









Emergency Contact


Diagnosis & ICD-10 Coding












Primary Insurance 









Secondary Insurance 









Prescribing Physician Information








Therapist Information











STM-10:



TR-10C:


My above signature indicates my approval of this order and it’s accuracy. *My above signature indicates my approval to ship the instrument to my patient’s home and releases Current Medical Technologies, Inc. from any liability from it’s use prior to proper instrument education and training. Please note, due to state regulations we are not allowed to ship direct to Tennessee. Maryland and Kansas residents.
If you have any questions, please contact Current Medical Technologies DME department 800-382-5879 ext. 4.