Prescription Form

Please print this page and have your doctor sign before submitting to your insurance company.

Name of Patient: _________________________________________

I have recommended the _______________________ (e-pill / CADEX /PuffMinder / HIprotector device)
for my patient to help with treatment and medication compliance for his/her

______________________________________
(patient's diagnosis)

Name and Address of Prescribing Doctor:

________________________________________

________________________________________

________________________________________

________________________________________

Signature: ________________________________ Date: __________

e-pill, LLC is not a Medicare Provider and does not bill Medicare. If you are a Medicare recipient you assume complete financial responsibility for your purchases. e-pill® is a registered trademark.


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e-pill 10TH ANNIVERSARY 1999-2009

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©Copyright e-pill, LLC 1997, 98, 99, 2000, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10 e-pill®, ePill®, CADEX®, HIProtector®, PuffMinder®, Medical Snooze™, Patient Compliance Dashboard™ and e-pill pager medical reminder™ are trade and service marks, reach us at http://www.epill.com or http://www.HIProtector.com or (800) 549-0095 or (781) 239-2941.
We accept: American Express AMEX, VISA, MasterCard, Discover and Diner's Club .

e-pill is the leading provider of medication reminder / patient compliance devices

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e-pill, LLC is not a Medicare Provider and does not bill Medicare. If you are a Medicare recipient you assume complete financial responsibility for your purchases. e-pill® is a registered trademark.

e-pill Medication Reminders
e-pill, LLC | 49 Walnut Street, Bldg. 4 | Wellesley, MA 02481, USA
www.epill.com | 1-800-549-0095 | +1 (781) 239-2941 | fax + 1 (781) 235-3252

e-pill Medication Reminders is Boston based medical device company. Since 1999 e-pill timers, watches, pill boxes and alarms have helped patients around the world remember to take medications on time (improve medication adherence / patient compliance).

This Web site (www.epill.com) is maintained by GigaNano - BioMedical Consultants
Copyright © 1997-2010 e-pill, LLC.