Modius Sleep Prescription
Modius Sleep is a noninvasive, non-drug and FDA cleared medical device indicated for the treatment of chronic insomnia in adults in US.
Medical Practice / Prescriber Information
Medical Practice
*
Prescriber Type:
*
Please Select
Physician
Nurse Practitioner
Physician Assistant
Prescriber Name:
*
Prefix
First Name
Last Name
Prescriber NPI #:
*
Prescriber Contact Number:
Please enter a valid phone number.
Patient Information
Patients Name:
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Modius Sleep is indicated for adults (22+) only.
Patient's Gender
*
Please Select
Male
Female
Other
Patient's Email Address:
*
[email protected]
Patient's Phone Number
*
Required for shipping
Patient Diagnosis
*
Please Select
G47.00 - Insomnia, unspecified
G47.01 - Insomnia due to medical condition
G47.02 - Insufficient Sleep Syndrome
G47.09 - Other Insomnia
Other
If "other", please describe
*
Please list any known comorbidities (e.g., diabetes, hypertension, sleep apnea, etc.)
Patient Baseline Insomnia Severity Index (ISI) Score
*
This should be a number between 0 - 28
Calculate Insomnia Severity Index (ISI) Score
Purchase / Rental
*
Please Select
Purchase
2 Month Rental
Purchase through VA Prosthetics Dept
Prescriber Signature:
Submit Prescription
Submit Prescription
Should be Empty:
