Proof of Delivery – Silicone Prosthesis | Realistic Prosthetics in Utah

Patient's Name

First

Last

Proof of Delivery

I received a prosthesis from Paul Tanner with Custom DME, LLC today and have been instructed how to use and care for my prosthesis.

Type of Prosthesis I Received

Additional Type of Prosthesis I received

Insurance and Financial Responsiblity

I am informed of the cost of this service. I give consent to bill my health insurance provider(s) and coordinate benefits. I am responsible for any remaining balance on the account.

I, the undersigned patient / responsible party, in order to assist in the dissemination of medical and scientific knowledge, or in the improvement of medical diagnosis and treatment, authorize Custom DME, LLC, to release, publish, display, or otherwise use photographs, models and / or video which are obtained in connection with my treatment. It is understood and agreed that names will not be used or in any way disclosed in connection therewith, without verbal and written consent and specified use.

I consent
I decline

Date / Time

Date

Time

Signature

Email

Parent/Guardian Name

First

Last

Welcome to Realistic Prosthetics! Paul Tanner,CCA is an Ocularist and Certified Anaplastologist. Paul is confident he can offer you excellent service. Paul is accepting new patients and works really hard to see patients in a timely manner.

Please call or text (801) 997-0545 with questions