Thanks for checking back in with us. It looks like we have your patient information, so you can close this window. If you have questions, please contact customer service at 800-935-7763 or customerservice@rsmedical.com between 7am – 5pm Mon-Fri. Patient Account Set Up To make sure we’re ready to ship when we receive your prescriber’s order, we need some information. First Name* Last Name* Date of Birth* Last 4 Digits of Social Security Number* SHOW Street Address* City* State/Province* --None-- Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip* Email Address* Home Phone Mobile Phone* Preferred Communication Method* --None-- Mobile Home Emergency Contact Name Emergency Contact Phone Prescriber Name Medical Facility Where is your primary source of pain located?*(Check all that apply) Head Neck Upper Back Shoulder Arm Elbow Wrist Hand Mid-Back Lower Back Hip Upper Leg Knee Lower Leg Ankle Foot If your order includes a garment, help us ensure the best fit by sharing your height and waist size. Height (Feet)* --None-- 3' 4' 5' 6' 7' Height (Inches)* --None-- 0" 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11" Waist Size* --None-- Small: 19-25 inches Medium: 25-36 inches Large: 36-45 inches X-Large: 45-55 inches XX-Large: over 55 inches E-mail, Voicemail and Text Message Consent We’d like to send updates as your order progresses. Giving consent allows us to message you. RS Medical will on occasion send appointment reminders and wellness messages related to your care to you via email, voicemail or text messages based on our understanding that you would like us to communicate with you via e-mail, voicemail or text messaging. These communications may come from our staff members or from our automated system. RS Medical is not responsible for any unauthorized access. RS Medical will never sell your information. Message and data rates may apply. I consent to RS Medical e-mail, voicemail and text messages. I will inform RS Medical if I no longer wish to communicate with RS Medical via e-mail, voicemail or text message. I would like to opt-in to receiving the latest information about RS Medical products and services. I understand that I am not required to Consent to be a patient of RS Medical. I Consent --None--Sent Granted Granted by Guardian Refused Revoked Viewed Upper Back Neck Shoulder Mid-Back Lower Back Hip Upper Leg Knee Lower Leg Ankle Foot Arm Wrist Elbow Hand Head Previous Next Next Submit