Efficient, Comfortable, Low-cost Solutions. Designed for dialysis patients

See what patients are saying:
"I am a patient ... in New Jersey. I am getting the treatment of Photopheresis , for side effects of a bone marrow transplant. I am very sensitive to certain products to use on the IV after treatment. Your Hemo product is wonderful. It works well and is tolerable to have on. I hope the establishment where the product was used gets more!"

HEMO

 

 

PRESCRIPTION AUTHORIZATION FORM

 

This prescription is for HEMO, and HEMO II. The product is provided by Innovations for Dialysis for use following dialysis. By signing this form the physician is authorizing the patient to purchase the product as needed for the amount of time specified. The maximum time for prescriptions is 24 months before a renewal is needed.

Note: Innovations for Dialysis will accept a standard prescription from the doctor in place of this form.

Dosage: One of two pads per hemodialysis treatment, to be used with compression (either manual or mechanical).

The prescription is for the patient listed below:

Patient:
This prescription is good for:
PRN   One Year
PRN    Two Years
  HEMO
  HEMO II
Physician:
(Print or Type):
Date:
Physician Address:
Physician Signature:

7272 SW Durham Road, Suite #800
Portland, Oregon 97224

(800) 345-0363


Fax: (503) 620-8336


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