Prescription Form / Rx

Prescription Form / Rx
Please print this page (Prescription Form / Rx Form) and have your doctor sign before submitting to your insurance company.



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)


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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