Follow the 5 steps below to create a letter to your doctor requesting ON-Q for your upcoming surgery.

  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:
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.

 

Sample Letter
(Click to Enlarge)


Copyright 2005 © I-Flow Corporation

There are inherent risks in all medical devices, please refer to the product labeling for Indications, Cautions, Warnings and Contraindications.For example, failure to follow the product labeling regarding filling, flow rate selection and placement of the pump and/or catheter could directly impact patient safety. Physician is responsible for prescribing and administering medications per instructions provided by the drug manufacturer.