1. Fill in the fields.
2. Click on the button below the fields to automatically generate your personal letter.
3. Print your letter and ON-Q Highlights page. Sign the letter.
4. Give or mail the letter and ON-Q Highlights to your doctor.
5. Don't forget to keep a copy for your records.

Printing this letter requires Adobe Acrobat Reader.
Click here to download Acrobat Reader.

Your Name:
Doctor's First Name:
Doctor's Last Name:
Hospital Name:
Street Address:
Address (line 2):
City:
State: ( select state ) AK AL AR AZ CA CO CT District of Columbia DE FL GA HI IA ID IL IN KY KS LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:

Note: If the automatic letter does not work on your computer, we apologize for the inconvenience. You may also click on the Sample Letter & ON-Q Highlights pages to the right, print both pages, fill in the information by hand, and give or mail it to your doctor.