NeuroVana Calm Ultra Medical Device Authorization Form
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Purchase Medical Device Authorization
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient
Details:
Full Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
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GAD-7 Anxiety Screening
Over the last two weeks, how often have you been bothered by any of the following problems?
Feeling nervous anxious, or on edge.
*
Not at All
Several Days
More than half the days
Nearly every day
Not being able to stop or control worrying.
*
Not at All
Several Days
More than half the days
Nearly every day
Worrying too much about different things.
*
Not at All
Several Days
More than half the days
Nearly every day
Trouble Relaxing.
*
Not at All
Several Days
More than half the days
Nearly every day
Being so restless that it is hard to sit still.
*
Not at All
Several Days
More than half the days
Nearly every day
Becoming easily annoyed or irritable.
*
Not at All
Several Days
More than half the days
Nearly every day
Feeling afraid, as if something awful might happen.
*
Not at All
Several Days
More than half the days
Nearly every day
If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Calculation
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The following questions are designed to assess risk factors involved in treatment. Selecting "Yes" does not disqualify you for the program, but will require further discussion with your provider.
Are you over the age of 18?
*
Yes
No
Do you have a parent/guardian's permission to purchase and use the Calm Ultra Device?
Yes
No
Do you have a medical device implanted in your head or neck?
*
Yes
No
Please consult with your provider before using the Calm Ultra
Do you have any implanted medical devices (pacemaker, insulin pump, pain pump, etc.)?
*
Yes
No
Please consult with your provider before using the Calm Ultra
Are you pregnant?
*
Yes
No
Please consult with your provider before using the Calm Ultra
Do you suffer from epilepsy or form of seizures?
*
Yes
No
Please consult with your provider before using the Calm Ultra
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Consent
I consent to be evaluated by an independent licensed healthcare provider for the purpose of determining whether a Calm Ultra device is appropriate for my symptoms
*
Yes
No
I understand that CES devices require a prescription and that approval is subject to provider evaluation.
*
Yes
No
I consent to receiving communication and medical documentation electronically, including follow-up by email or phone.
*
Yes
No
I acknowledge that my responses are protected under HIPAA and will be kept confidential. I understand that Neurovana Calm complies with all HIPAA standards.
*
Yes
No
I understand that CES devices are FDA-cleared for the treatment of anxiety, insomnia, and depression, but individual results may vary.
*
Yes
No
fpr
sca_ref
I affirm that I have answered all questions honestly to the best of my ability.
*
Yes
No
Submit
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