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