Prescription Form / Rx
![Prescription Form / Rx](https://s.turbifycdn.com/aah/epill/epill-prescription-rx-form-14.png)
Name of Patient: _________________________________________
I have recommended the _______________________ (e-pill device)
for my patient to help with treatment and medication compliance for his/her
______________________________________
(patient's diagnosis)
________________________________________
________________________________________
________________________________________
________________________________________
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.