Gibraltar Electro Medical Services
Drug Free Pain Relief
Forms and Charts

To ensure a GEMS-TENS patient has sufficient supplies to follow the prescribed treatment regimen, GEMS will provide these supplies when the patient is referred to GEMS by their physician.  In order to provide a GEMS-TENS patient with TENS supplies, the following "Patient Intake Form" and "Prescription / Certificate of Medical Necessity" must be filled out, signed and dated.  Below, you will find a copy of the "Prescription / Certificate of Medical Necessity" and the "Patient Intake Form."  Both can be filled out on your computer, then printed.  A sample copy of each, for a fictional patient, is also provided below.

Insurance Verification Form for Physicians

Patient Intake Form

Patient Intake Form - Sample

Prescription / Certificate of Medical Necessity

Prescription / Certificate of Medical Necessity - Sample


The following electrode placement charts are simply for informational purposes.  Only a physician should instruct a patient on how to use a GEMS-TENS, and where to place the electrodes.

Blank Electrode Placement Chart

Sciatica Electrode Placement Chart

Low Back Electrode Placement Chart

Back, Hip, or Knee Degenerative Joint Disease

Knee Osteoarthritis or Rheumatoid Arthritis