YOUR PHYSICIAN HAS PRESCRIBED THE AIRCAST ® CRYO/CUFF ™ IC AS PART OF YOUR RECOVERY PROGRAM. The therapeutic effects of compressive cold are recognized by practitioners, as well as patients, as a useful method for reducing the symptoms of pain and swelling while providing comfort following trauma or surgery. Further, the use of compressive cold has been proven to reduce the need for narcotics and to help accelerate rehabilitation. WHAT IS THE AIRCAST ® CRYO/CUFF ™ IC? The Cryo/Cuff ™ IC is a post-operative device that provides automated compression and cold therapy to help treat swelling and pain. The Unit information contained in this Form is not a substitute for the Operating Instructions that are to be provided with the Unit. By signing the Cold Therapy Order Form on the reverse, you acknowledge that you must carefully read and follow the Operating Instructions that are to be provided with the Unit before your use. You also acknowledge that you must immediately contact your physician for medical treatment advice if you experience any discomfort when using the Unit. Extreme care must be taken when using any cryotherapy as it may cause cold injury and/or frostbite when improperly used. DJO, LLC I A DJO Global Company T 800.336.6569 F 800.936.6569 1430 Decision Street I Vista, CA 92081-8553 I U.S.A. djoglobal.com/aircast | [email protected]

Fill out your credit card and shipping information below. Obtain your physician’s authorization signature on this order form. Fax or email this form with physician’s information, physician signature and credit card information to 1-800.936.6569 or [email protected] COLD THERAPY ORDER FORM COLD THERAPY PRESCRIPTION Physician Authorization Fax form to 800.936.6569 or email to [email protected] I authorize the use of the AirCast® Cryo/Cuff ™ IC unit for this patient. To receive the Cryo/Cuff ™ IC, complete this form. Your credit card will be billed for the unit plus shipping and...