Prescription Form for Trachi-Naze Plus Stoma Stud

>Orders must be from a licensed practitioner trained in the care and rehabilitation of people with laryngectomies and tracheotomies - ie. Physicians, Speech Pathologists, Respiratory Therapists.

>This form may be copied and used as needed for your patients - or your own prescription form or letterhead may be used, if preferred, as long as it contains the information requested below.

>Standing orders should be renewed yearly. Any change in length or diameter of Trachi-Naze Plus Stoma Stud for an individual patient requires a new prescription.

>Filters for the Stoma Studs come in Day, Night and Active versions and do not require a prescription. PLEASE PRINT OR WRITE VERY CAREFULLY

Clinician_______________________________________________________________

Address_______________________________________________________________

City___________________________________State_________Zip________________

Licensee#_____________DEA Reg.#______________Medicare UPIN #____________

Phone___________________Fax__________________ e-mail___________________

____  Please send the filled prescription to my patient as he/she needs and requests:

Patient Name___________________________________________________________

Address_______________________________________________________________

City___________________________________State_________Zip________________

Phone___________________Fax__________________ e-mail___________________

Supply Trachi-Naze Plus Stoma Studs, in the size marked below:

LENGTH, INNER DIAMETER, OUTER DIAMETER, Kapitex Cat.#, Luminaud Cat.#

_____14.5 mm 8 mm 10.5 mm   2001 38071

_____ 14.5 mm 10 mm 12.5 mm   2002 38072

_____ 14.5 mm 12 mm 14.5 mm   2003 38073

_____14.5 mm 14 mm 16.5 mm   2004 38074

_____ 14.5 mm 16 mm 18.5 mm   2005 38075

_____ 22.5 mm 8 mm 10.5 mm     3001 38076

_____ 22.5 mm 10 mm 12.5 mm   3002 38077

_____ 22.5 mm 12 mm 14.5 mm   3003 38078

_____22.5 mm 14 mm 16.5 mm   3004 38079

_____ 22.5 mm 16 mm 19.5 mm   3005 38080

Signature _______________________________________ Date__________________

MAIL OR FAX COMPLETED PRESCRIPTION, WITH FIRST ORDER, TO:
LUMINAUD, INC., 8688 Tyler Blvd., Mentor, OH 44060  - Fax: 440-255-2250
FEDERAL ID #34-1268969 - MEDICARE PROV. # 0246490001