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: 1-617-507-6448

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:
-   Sweet Beats 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

___________________________________________________

Sweet Beats 7493 N. Oracle Rd. Suite 103, Tucson, AZ 85704
Phone: 800 242-5421   Fax: 617 507-6448   www.sweetbeats.net