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Breast Pump Order Form

Breast Pump (Chooe One)

I certify that the equipment and supplies I prescribed are Medically Necessary for this patient's wellbeing. In my professional opinion, the equipment is both reasonable and necessary in reference to the accepted standards of medical practice and treatment for this patient's condition. It is NOT prescribed as convenience equipment.

Physician Information

Print this order out to give to the patient and have them call us, or fax to us this form, patient demographics & insurance to (315)782-4496

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