Cartridge Form
spacer.gif (877 bytes)
spacer.gif (877 bytes)
Home Up Contents Search Feedback Contact TAIspacer.gif (877 bytes)spacer.gif (877 bytes)

cart.gif (31989 bytes)

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."

Cartridge
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): ___

 

Therapeutic Alliances Inc.
333 North Broad Street - Fairborn, OH 45324  USA
(937) 879-0734 - (937) 879-5211 (fax)   www.MusclePower.com

This page and all Therapeutic Alliances-designed link pages are Copyright 1996-2012 Therapeutic Alliances Incorporated, Fairborn, Ohio USA. All rights reserved. Therapeutic Alliances Inc., ERGYS®, REGYS, SpectraSTIM®, NeuroEDUCATOR®, Stimwear®, "You Are the Moving Part," and "The Power of Your Muscles" are trademarks of Therapeutic Alliances Inc. Control Bionics and NeuroSwitch are trademarks of Control Bionics Inc. Parastep is a trademark of Sigmedics Inc.

Send mail to info@ERGYS.com with questions or comments about this web site.