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REFER A PATIENT

Before making a referral, referred patient must first be informed and have voluntarily consented to the referral.

 

 

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REFERRING PHYSICIAN INFORMATION:
NAME:
PHONE NUMBER:
EMAIL:
RESEARCH STUDY FOR WHICH YOU ARE REFERRING PATIENT:

TO CONFIRM, DOES PATIENT KNOW HE/SHE IS BEING REFERRED?
Yes No

PATIENT INFORMATION:
NAME:
PHONE NUMBER:
EMAIL:


BECOME A PRINCIPAL INVESTIGATOR OR CO-INVESTIGATOR


NAME:
NAME OF PRACTICE:
ADDRESS:
CITY:
STATE:
ZIPCODE:
FIELD OF PRACTICE/SPECIALTY:
PHONE NUMBER:
EMAIL:
RESEARCH STUDY IN WHICH YOU ARE INTERESTED:


CONTACT US

Pico-Tesla Magnetic Therapies
4700 140th Ave. N., Suite 101
Clearwater, FL 33762

phone: 727-474-3722
e-mail: info@pico-tesla.com

 
 

4700 140th Ave. N., Suite 101 • Clearwater, FL 33762 • 727-474-3722

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The Resonator™ device is an Investigational Device limited by Federal (or United States)
law to investigational use. The Resonator™ device is not for sale, nor is the Magneceutical™
Therapy generally available outside of Investigational Review Board (IRB) approved clinical studies.