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# 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:**