Prescription Form / Rx

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

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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: __________

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