RX - Neurovalens

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
UID
Medical Practice*
Prescriber Type:*
Prescriber Name:*

PrefixFirst NameLast Name
Prescriber NPI #:*
Prescriber Contact Number:
Please enter a valid phone number.
Prescriber Email Address:*
We will send the completed prescription to this email address for signature once submitted.
Patient Information
Patients Name:*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Modius Sleep is indicated for adults (22+) only.
Patient's Gender*
Patient's Email Address:*
example@example.com
Patient's Phone Number*
Required for shipping
Patient Diagnosis*
If "other", please describe*
Please list any known comorbidities (e.g., diabetes, hypertension, sleep apnea, etc.)
Patient Baseline ISI (Insomnia Severity Index) Score*
This should be a number between 0 - 28
Patient Baseline Insomnia Severity Index (ISI) Score*
This should be a number between 0 - 28
Calculate Insomnia Severity Index (ISI) Score
Purchase / Rental*
Prescriber Signature:*

Clear
Should be Empty:

Modius Sleep Prescription