Order

To order, you may download a copy of the order form from the documents section and fax it to Peak Medical Group @ 1-780-757-0042, or you may email a scanned version to email .

Order Online

You may also order online by completing the form below. You will receive an order confirmation upon submission and will be contacted if we require any additional information regarding your order.

Patient Name:

Patient Email:

Patient Phone:

Patient Address:
(where the device will be shipped)

Healthcare Provider:
(for billing purposes if at public hospital)

Date of Surgery (mm/dd/yyyy):

Location of Surgery:

Hospital:

Private Payer
Publicly Funded

Start Date of Therapy (mm/dd/yyyy):

Area of Therapy:

Knee
Shoulder
Hip
Back
Ankle
Wrist

Other:

DVT Therapy:

Yes
No

Size of Disposable Wrap:

Standard (most patients)
Medium (BMI > 40)
Large (please consult Peak Medical)

Therapy Modality:
(check box(es) in accordance with
desired treatment)

Cooling
Heating
Compression

Number of Therapy Days:

10 Days
14 Days
21 Days
28 Days

Other:

Number of Therapy Hrs Per Day:

Treament Recommended By:

Office Contact Information:

Additional Comments: