Please take (or fax) this to your licensed caregiver and fax it to us. This is an FDA regulation.
Your order will not ship without a signed prescription form from a licensed caregiver.
Please fax to: 1-561-394-3983

Prescription for Home Use of Fetal Doppler


Date__________________________________________________________



Patient Name___________________________________________________


The patient above has requested a fetal Doppler for home use.
She has provided your information as her caregiver.
Please approve her rental or purchase of a fetal Doppler.

Our fetal Doppler Rental Package includes:
-   Stork Radio Fetal Doppler (2 or 3 mhz probe, model dependant)

-   Information containing usage and safety information

-   Owner’s Manual

-   Tube of ultrasound gel
Licensed Caregiver’s Name (Printed)

___________________________________________________


Caregiver’s phone number

___________________________________________________


Caregiver’s Signature

___________________________________________________

Stork Radio, LLC 2000 NE 5th AVE, Boca Raton, FL, 33431
Phone: 561-392-9223   Fax: 561-394-3983   www.storkradio.com