Physician Prescription Form
ALL SECTIONS MUST BE FILLED OUT COMPLETELY
Computer Filable PDF
| PATIENT INFORMATION | |||||
|---|---|---|---|---|---|
| First Name | Last Name | Phone Number | |||
| Street Address | City | State Zip | |||
| Date of Birth (MM/DD/YYYY) | Email Address* |
| Primary Diagnosis | ||
|---|---|---|
| CVA | MS | SCI |
| Other (Specify) | ||
| ICD-10 Code: | ||
| Affected Lower Limbs | ||
| Left | Right | |
| Other Comments | ||
Indications for Use:
The Cionic Neural Sleeve 2 (NS-200) is intended to provide ankle dorsiflexion and/or plantarflexion and/or eversion in adult individuals with foot drop and/or to assist knee flexion or extension in adult individuals with muscle weakness related to upper motor neuron disease/injury (e.g. stroke, damage to pathways to the spinal cord). The Cionic Neural Sleeve NS-200 electrically stimulates muscles in the affected leg to provide ankle dorsiflexion and/or plantarflexion and/or eversion of the foot and/or knee flexion or extension; thus, it may also improve the individual's gait.
The Cionic Neural Sleeve NS-200 may also:
- Facilitate muscle re-education
- Prevent/retard disuse atrophy
- Maintain or increase joint range of motion
- Increase local blood flow
As a powered muscle stimulator, the Cionic Neural Sleeve NS-200 is indicated for the following conditions:
- Relaxation of muscle spasm
As a biofeedback device, the Cionic Neural Sleeve NS-200 is indicated for the following conditions:
- Biofeedback, relaxation, and muscle re-education purposes
Contraindications:
Individuals with implanted demand-type cardiac pacemakers or defibrillators should not use the Cionic Neural Sleeve; it should not be used over malignant tumors; it should not be placed over any areas where existing thrombosis is present; and it should not be used on a leg where a regional disorder, such as fracture or dislocation, could be adversely affected by motion from stimulation.
| PHYSICIAN INFORMATION | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Name | License # | NPI # | ||||||||||||
| Street Address | City | State | Zip | |||||||||||
| Phone Number | Office Contact | |||||||||||||
| I certify that the above-prescribed device is medically indicated and in my opinion is reasonable and necessary for this patient's treatment. | ||||||||||||||
| Physician Signature | Date |
772-00792 Rev A Last Revision 2/11/2026
Patient Considerations
- For home use, the patient needs to be able to ambulate independently, with or without an assistive device
- Does not exclude patients who would use the device for seated exercises in home and are working toward independent ambulation in physical therapy
Contraindications
- Implanted demand-type cardiac pacemakers or defibrillators
- Use over malignant tumors
- Use over an existing thrombosis
- Use over a fracture or dislocation, or where movement is contraindicated
Other Considerations & Precautions
- Limited hand dexterity for donning/doffing
- Recent or uncontrolled seizures
- Edema or swelling that could impact the effectiveness of stimulation
- Areas of skin on the leg(s) that are frequently open or infected
Taking Accurate Measurements
- Use a measuring tape to help patients take accurate measurements while standing
| Thigh | Calf | Inseam | |
|---|---|---|---|
| Extra Small | 15"-21" | 9.5"-14.5" | ≥24" |
| Small | 17"-23" | 11"-15.5" | ≥25" |
| Medium | 19"-25" | 12"-17" | ≥25.5" |
| Large | 22"-28.5" | 14"-19" | ≥26" |
| Hybrid LS | 22"-28.5" | 11"-15.5" | ≥25.5" |
772-00793 5HY 5HYLVLRQ
Current Sizing Chart: