To ensure a GEMS-TENS patient has sufficient supplies to follow the prescribed treatment regimen, GEMS will provide these supplies when the patient is referred to GEMS by their physician. In order to provide a GEMS-TENS patient with TENS supplies, the following "Patient Intake Form" and "Prescription / Certificate of Medical Necessity" must be filled out, signed and dated. Below, you will find a copy of the "Prescription / Certificate of Medical Necessity" and the "Patient Intake Form." Both can be filled out on your computer, then printed. A sample copy of each, for a fictional patient, is also provided below.
Insurance Verification Form for Physicians
Patient Intake Form
Patient Intake Form - Sample
Prescription / Certificate of Medical Necessity
Prescription / Certificate of Medical Necessity - Sample
ELECTRODE PLACEMENT CHARTS
The following electrode placement charts are simply for informational purposes. Only a physician should instruct a patient on how to use a GEMS-TENS, and where to place the electrodes.
Blank Electrode Placement Chart
Sciatica Electrode Placement Chart
Low Back Electrode Placement Chart
Back, Hip, or Knee Degenerative Joint Disease
Knee Osteoarthritis or Rheumatoid Arthritis