Vivally RX

First Name *

Last Name *

Gender *

DOB (MM/DD/YYYY) *

Phone Number

Shoe Size

Men's Women's

Wide Fit?

Yes No

Ankle Circumference (in)

Measure above ankle bone

Prescriber Information

This form serves as a Standard Written Order and Prescription for the Vivally System for this patient. As this patient’s Prescriber, I attest that the clinical information in this document accurately reflects the patient’s health status and condition. I further certify that the Vivally System is reasonable and medically necessary for the treatment of this patient’s condition. I understand that my email address and a secure login to the Vivally System may be required for me to access Vivally System data for this patient.

Recommended fields (email may be required for access to patient Vivally therapy data):

Patient Information

Prescriber Information